'f-fCfAfT;  'GEY-jIff; 


ECLECTIC  OBSTETRICS 


- 


Rewritten,  Revised  and  Enlarged 


ROBERT  C.  WINTERMUTE,  M.  D. 

I'UOFKSSOK    OF    OMSTKTKIC'S    AM)    DISEASES   OF    WOMEN    AND    CHILDREN*    IN    THE    ECLECTIC 
MEDICAL    INSTITUTE    OK    CINCINNATI. 


NINTH  EDITION. 


CINCINNATI : 

THE  OHIO  VALLEY  COMPANY. 
1892. 


Entered  according  to  Act  of  Congress,  in  the  year  1855,  by 

MOORE,  WILSTACH,  KEYS  &  CO., 
In  the  Clerk's  office  of  the  District  Court  for  the  Southern  District  of  Ohio. 

Entered  according  to  Act  of  Congress,  in  the  year  1S6G,  by 

MOORE,  WILSTACH  &  BALDWIN, 
In  the  Clerk's  office  of  the  District  Court  for  the  Southern  District  of  Ohio. 

Entered  according  to  Act  of  Congress,  in  the  year  1875,  by 

WILSTACH,  BALDWIN  &  CO., 
In  the  office  of  the  Librarian  of  Congress  at  Washington. 

Copyright,  1892,  by 
THE  OHIO  VALLEY  COMPANY. 


ROBERT  C.  WINTEBMUTE,  M.  D., 

1 33  W.  Seventh  Street,  Cincinnati,  0.  : 

DEAR  SIR — When  my  feeble  health,  two  years  ago,  compelled  me 
to  resign  my  position  as  Professor  of  Obstetrics,  I  realized  that  I  would 
never  have  the  strength  to  revise  my  book  on  Obstetrics.  I  had 
felt  the  necessity  for  such  a  revision  for  several  years,  and  the  ques- 
tion arose — who  would  do  it?  Fortunately,  you  consented  to  under- 
take the  work,  although  already  burdened  by  the  duties  of  your 
Professorship  of  Obstetrics  and  Diseases  of  Women  and  Children, 
in  my  place,  at  the  Eclectic  Medical  Institute  of  Cincinnati.  Your 
task  for  more  than  a  year  has  been  a  difficult  one,  but  your  faithful 
work  has  at  last  been  completed,  and  I  offer  you  my  congratulations 
on  your  success.  I  now  feel  that  my  confidence  in  you  was  well 
placed,  and  that  the  new  Obstetrics  will  be  all  that  is  required  by 
practitioners  and  students,  especially  in  regard  to  the  use  of  specific 
remedies  and  therapeutics.  .  Yours,  very  truly, 

XOUTH  BEND,  O.,  May  27,  1892. 


3  7 


PREFACE  TO  NINTH  EDITION, 


Ox  being  called  to  the  chair  of  Obstetrics  in  the  Eclectic  Medical 
Institute  two  years  ago,  my  attention  was  at  once  called  to  the  fact 
that  a  new  and  revised  edition  of  the  text-book  of  the  department  was 
badly  needed.  The  broken  health  and  advanced  age  of  the  author 
rendered  it  impossible  for  him  to  undertake  the  work;  it  thus 
devolved  upon  me  to  make  the  revision.  Arrangements  being  com- 
pleted with  Dr.  King,  I  at  once  set  about  the  task  of  overhauling  the 
old  and  building  up  the  new.  The  great  advance  that  has  been  made 
in  the  art  and  science  of  obstetrics  during  the  past  fourteen  years  (the 
time  since  the  last  revision  by  Prof.  King)  has  rendered  necessary  a 
thorough  and  systematic  rewriting  of  the  entire  work,  in  order  to 
bring  it  up  to  the  present  state  of  knowledge  on  the  subject.  I 
assumed  the  responsibility  of  the  work  with  a  very  keen  sense  of  the 
many  difficulties  and  great  labor  involved  in  the  undertaking. 
Numerous  and  extensive  additions  have  been  made  to  every  chapter 
of  the  work.  Especial  attention  is  called  to  the  treatment  of  the  dis- 
eases of  pregnancy ;  specific  medication  being  substituted  for  the  old 
style  of  prescribing.  Where  reference  is  made  to  remedial  agents,  the 
specific  tinctures  peculiar  to  the  eclectic  school  of  medicine  are 
understood. 

For  valuable  suggestions  from  Prof.  J.  M.  Scudder,  and  the  late 
Prof.  HoAve,  also  cuts  Xos.  50,  55,  76,  and  81,  kindly  loaned  me  by  the 
latter,  I  must  acknowledge  my  obligations. 

This  work  is  here  submitted  to  the  profession  in  the  hope  that,  as 
now  issued,  it  may  meet  the  requirements  both  of  a  text-book  for  the 
student  and  a  work  of  reference  for  the  busy  practitioner,  as  I  have 
endeavored  to  present  a  clear  and  practical  description  of  the  subject 
in  question. 

R.  C.  WINTERMUTE,  M.D. 

CINCINNATI,  July  1, 


-73' 


PREFACE  TO  THIRD  EDITION, 


IN  presenting  this  new  edition  of  the  "American  Eclectic  Obstetrics  " 
to  the  profession,  it  may  be  proper  to  state  that  the  work  has  been 
subjected  to  a  thorough  revision.  For  the  purpose  of  presenting  a 
more  regular  and  systematic  study  of  the  subjects  treated  upon,  some 
modifications  have  been  made  in  the  arrangement  of  the  First  and 
Second  Parts  of  the  previous  edition,  which  it  is  believed  will  meet 
with  the  approval  of  the  reader. 

Owing  to  the  publication  of  the  American  Dispensatory,  and  various 
other  Eclectic  works  on  Materia  Medica  and  Practice,  in  which  the 
therapeutical  agents  pertaining  to  the  department  of  Obstetrics  are 
fully  and  accurately  described,  it  has  been  deemed  advisable  to  omit 
Part  Six  of  preceding  editions;  this  exclusion  has  permitted  consid- 
erable additions  to  the  work  without  an  unnecessary  increase  in  the 
number  of  its  pages.  Some  idea  of  the  additions  made  may  be  formed, 
when  it  is  observed  that  at  least  seventy  pages  of -the  last  edition  have 
been  entirely  excluded,  the  greater  portion  of  which  is,  in  the  present 
work  (and  independent  of  revisions  and  other  additions),  occupied  with 
new  and  valuable  matter  (about  sixty-three  pages).  The  recent  prog- 
ress in  the  Obstetrical  Department  of  Medical  Science  has  rendered 
these  additions  very  necessary. 

It  has  been  the  Author's  endeavor  to  render  the  work  satisfactory, 
thorough,  and  essentially  practical  for  both  practitioners  and  students, 
and  he  confidently  believes  that  it  will  be  found  at  least  approximat- 
ing these  qualities,  and  in  no  way  secondary  to  its  predecessors. 

For  the  many  favors  and  kindnesses  received  from  Eclectics,  and 
from  the  medical  profession  generally,  the  author  avails  himself  of 
this  opportunity  to  express  his  assurances  of  great  regard  and  pro- 
found gratitude. 

JOHN  KING. 


CONTENTS. 


PAGE 

CHAPTER  I.     Woman 11 

CHAPTER  II.     The  Pelvis:    "True"  and  "False" — Difference  between  Male 

and  Female  Pelvis :  Pelvic  Articulations,  etc 16 

CHAPTER  III.     Syniphyses  and  Ligaments  of  the  Pelvis 23 

CHAPTER  IV.     Straits  and  Cavities  of  the  Pelvis — The  Pelvis  as  a  whole 29 

CHAPTER  V.     Deformities  of  the  Pelvis 35 

CHAPTER  VI.     Indications  of  Malconformation  of  the  Pelvis 47 

CHAPTER  VII.     The  Fetus,  its  Divisions  and  Dimensions 54 

CHAPTER  VIII.     The  Female  Organs  of  Generation 61 

CHAPTER  IX.     The  Internal  Organs  of  Generation - 68 

CHAPTER  X.     Of  the  Uterine  Appendages — -The  Ligaments,  the  Fallopian 

Tubes,  and  the  Ovaries 81 

CHAPTER  XL     Of  the  Corpus  Luteum 88 

CHAPTER  XII.     Theories  of  Impregnation 94 

CHAPTER  XIII.     Menstruation — Ovulation — Conception 100 

( 'HAPTER  XIV.     Development  of  the  Human  Ovum 109 

CHAPTER  XV.     Of  the  Fetus  and  its  Development 128 

CHAPTER  XVI.     Position,   Nutrition,   Respiration,   Circulation,    Dimensions, 

and  Death  of  the  Fetus — Superfetation 142 

CHAPTEU  XVII.     Changes  in  the  Condition  of  the  Uterus  during  Pregnancy.   156 

CHAPTER  XVIII.     Of  Pregnancy 171 

CHAPTER  XIX.     Compound  and  Mixed  Pregnancy. 178 

CHAPTER  XX.     Signs  of  Pregnancy 190 

('HAPTER  XXI.     Diseases  of  the  Pregnant  Female 209 

(  'HAPTER  XXII.     Diseases  of  the  Pregnant  Female — Continued 234 

CHAPTER  XXIII.     Hemorrhage  and  Abortion 249 

CHAPTER  XXIV.     Labor 271 

CHAPTER  XXV.     Management  of  Natural  Labor 285 

CHAPTER  XXVI.     Attentions  Required  Subsequent  to  Delivery,  during  the 

Puerperal  Period 318 

CHAPTER  XXVII.     Presentations  and  Positions 332 

CHAPTER  XXVIII.     Mechanism  of  Labor 340 

CHAPTER  XXIX.     On  Difficult  Labor — First  Stage 358 

CHAPTER  XXX.     Difficult  Labor — Second  Stage :'>77 

CHAPTER  XXXI.     On  Difficult  Labor,  from  Tumors,  Pelvic  Deformities,  etc..  390 
CHAPTER  XXXII.    On  Difficult  Labor  from  Faulty  Conditions  of  the  Child, 

Mai-position  of  the  Head,  etc 407 

CHAPTER  XXXIII.     On  Preternatural  Labor — Pelvic  Presentations 429 

CHAPTER  XXXIV.    Of  Preternatural  Labor — Shoulder  Presentations 446 

CHAPTER  XXXV.     On  Preternatural  Labor — Transverse  Presentations — Pro- 
lapsus of  the  Umbilical  Cord — Plurality  of  Children — Monsters -168 

9 


10  CONTENTS. 


PAGE 

CHAPTER  XXXVI.  Complicated  Labor — Uterine  Hemorrhage  from  Placenta 

Prtcvia — Puerperal  Hemorrhage — Placental  Presentation 484 

CHAPTER  XX XVII.  Complicated  Labor — Treatment  of  Placenta  Prsevia — 

Syncope  from  Hemorrhage 491 

CHAPTER  XXXVIII.  Complicated  Labor — Accidental  Hemorrhage  —  Con- 
cealed Hemorrhage — Hemorrhage  After  Placental  Delivery — Effects  of 
Loss  of  Blood .« 502 

CHAPTER  XXXIX.  Complicated  Labor — Retention  of  the  Placenta — Hour- 
glass Contraction — Morbid  Adhesion  of  the  Placenta — Putrefactive 
Absorption 522 

CHAPTER  XL.  Complicated  Labor — Inversion  of  the  Uterus — Rupture  of  the. 
Uterus — Rupture  of  the  Vagina — Rupture  of  the  Bladder — Syncope — 
Thrombus 537 

CHAPTER  XLI.  Complicated  Labor  —  Puerperal  Convulsions  —  Eclampsia — 

Hysterical  Convulsions — Apoplexy — Epilepsy 552 

CHAPTER  XLII.  Turning,  or  Version — Cephalic  Version — Podalic  Version — 
The  Fillet— The  Vectis,  Lever,  or  Tractor— Blunt  Hook— Placental 
Forceps 573 

CHAPTER  XLIII.  The  Forceps — Davis'  Forceps— Hodge's  Forceps — Cases  in 
which  to  be  used — Cases  in  which  not  to  be  used — Period  for  using 
them 586 

CHAPTER  XLIV.  Rules  for  Applying  the  Foi'ceps  —  Mode  of  Applying  the 

Forceps  in  the  Various  Positions  of  the  Head 602 

CHAPTER  XLV.  Mode  of  Applying  the  Forceps  at  the  Brim — In  Face  Pres- 
entations, and  in  Pelvic  Presentations 615 

CHAPTER  XLVI.  Craniotomy — Perforator — Crotchet — Cesarean  Operation — 

Symphyseotomy (i22 

CHAPTER  XLVII.    Induction  of  Premature  Labor — (540 

CHAPTER  XLVIII.  Puerperal  Fever — Peritonitis — Puerperal  Septicemia — 
Inflammation  of  the  Uterine  Appendages — Metritis — Uterine  Phlebitis 
— Inflammation  of  the  Uterine  Absorbents — Treatment  of  Puerperal 
Fever 654 

CHAPTER  XLIX.  Phlegmasia  Dolens — Crural  Phlebitis — Treatment  of  Phleg- 

masia  Dolens. 680 

CHAPTER  L.  Phrenitis — Puerperal  Mania — Treatment  of  Puerperal  Mania — 

Intestinal  Irritation — Acute  Tympanitis — Diarrhea 691 

CHAPTER  LI.  Inflammation  of  the  Breasts — Mammary  Abscess — Ephemeral 

Fever — Weed — Miliary  Fever — Sore  Mouth  of  Nursing  Women 700 

CHAPTER  LII.  Cyanosis— Retention  of  Urine — Red  Gum — Jaundice — Infan- 
tile Ophthalmia — Flatulent  Colic — Constipation — Umbilical  Hernia — 
Excoriation  of  the  Navel — Hemorrhage  from  the  Cord — Hemorrhage 
from  the  Navel — Nsevus  Materni — Tongue-tied — Hydrocele — Swelling 
of  the  Breasts — Hare-lip 713 

CHAPTER  LIII.  Aphthse,  Thrush — Trismus  Nascentium — Porrigo  Larvalis, 

Milk  Scab .  722 


KING'S 


ECLECTIC  OBSTETRICS. 


THE  ART  OF  MIDWIFERY,  AND  SCIENCE  OF  OBSTETRICS. 


CHAPTER    I. 

WOMAN. 

THE  professional  delivery  of  women  has  been  an  art  ever  since  the 
human  race  had  a  history — ever  since  the  race  began — and  improve- 
ment in  methods  took  place  as  observation  extended  and  experience 
developed  knowledge.  During  periods  of  savagery  and  barbarism 
there  may  have  been  little  progress  in  the  rudest  of  arts,  when  knowl- 
edge was  traditional,  and  nothing  was  recorded  for  the  instruction 
of  coming  generations.  The  wives  of  the  builders  of  the  pyramids 
and  the  bondwomen  whom  Moses  led  out  of  Egypt  were  delivered 
with  some  degree  of  skill — with  the  advantages  to  be  derived  from 
experience ;  yet  enlightened  obstetricy  was  evolved  only  as  progress 
developed  in  other  branches  of  learning.  Substantial  progress  is  of 
slow  growth.  Great  discoveries  do  not  spring  from  the  brain  of  any- 
body as  fabled  Minerva  came  from  the  head  of  Jove.  The  art  of 
delivering  a  parturient  woman  is  merely  a  professional  matter — a  de- 
gree of  tact  acquired  by  the  ordinary  midwife,  and  not  much  improved 
upon  ;  but  the  science  of  obstetrics  pertains  to  the  evolution  of  the 
human  race,  and  bears  upon  the  origin  and  descent  of  mankind. 
11 


12  KIX(i's    KCLKCTIC    OHSTKTUICS. 

The  science  <>f  obstetriey  takes  j)l]ilosoj)hical  cognizance  of  differ- 
entiation in  sex  ;  woman  is  to  be  studied  in  all  her  peculiar  physical, 
mental,  moral,  and  sentimental  peculiarities,  and  as  a  creature  quite 
at  variance  with  man — her  companion  and  admirer.  Woman  is'  not 
originally  xi<!  </ntcrix,  but  spiritually  peculiar.  She  is  moved  by  sen- 
timents her  partner  in  life  never  feels;  she  is  swayed  by  impulses  a 
man  never  experiences. 

A  French  writer,  Colombat  de  L'Isere,  says  of  woman :  "  Feeble 
and  sensitive  at  birth,  and  destined  by  nature  to  give  us  existence; 
and  by  means  of  her  tender  and  watchful  care  to  preserve  us  after- 
ward, woman,  the  most  faithful  companion  of  man,  may  be  regarded 
as  the  very  complement  of  the  benefits  bestowed  upon  us  by  the 
Divine  Being  —  as  an  object  fitted  to  excite  our  highest  interest,  and 
as  presenting  to  the  philosopher,  as  well  as  to  the  physician,  a  vast 
field  for  contemplation. 

"  What  subject,  indeed,  is  more  worthy  of  our  attentive  meditation 
than  the  series  of  changes — physical,  moral,  and  physiological — that 
accompany  every  stage  of  woman's  existence.  Through  a  long  suc- 
cession of  modifications  and  revolutions,  she  discloses  all  the  phases 
of  her  constitution.  In  infancy  she  differs  slightly  from  the  male  in 
whose  pleasures  and  amusements  she  participates,  as  well  as  in  his 
dispositions  and  tastes,  his  inconstancy  and  vivacity.  At  that  early 
period — ignorant  of  her  own  sex,  ignorant,  so  to  speak,  of  her  own 
nature — the  blush  of  modesty  does  not  mantle  on  her  cheek :  and  her 
eyes,  which  reveal  no  passions,  seem  to  seek  only  what  has  reference 
to  her  real  wants. 

"Although  at  this  early  epoch  her  body  is  but  a  sketch  of  the 
forms  it^is  destined  to  assume  at  a  later  period,  she  always  retains, 
even  after  her  entire  development,  some  touch  of  the  softness  and 
delicacy  peculiar  to  her  childhood,  and  does  not  depart  so  widely  as 
her  playmate  from  the  idea  of  her  original  constitution. 

"  The  reproductive  faculty  divides  the  life  of  the  female  into  three 
very  distinct  periods  or  stages.  In  the  first,  this  property  has  no  ex- 
istence: in  the  second,  it  is  in  full  activity;  and  in  the  third,  it  has 
become  null  again.  The  duration  of  the  first,  commonly  decides  that 
of  the  two  last  periods;  so  as  to  establish  the  general  rule  that  the  old 
age  of  woman  comes  earlier  in  proportion  as  her  puberty  has  been 
more  precocious. 

'  The  vital  forces  that  regulate  the  organic  system,  and  the  organs 
that  constitute  that  system,  gradually  increase  during  the  first  period 


WOMAN.  13 

of  life:  they  attain  their  perfect  development;  and  diminish  and  be- 
come extinct  at  the  close  of  the  third,  whose  term,  like  that  of  the 
others,  may  be  accelerated  or  retarded  by  different  accidental  causes  and 
circumstances,  dependent  on  certain  physical  and  moral  conditions. 

"Upon  setting  out  in  the  career  of  life,  the  two  sexes  exhibit 
.nearly  the  same  physiognomical  characters  and  the  same  delicacy  of 
organization.  Their  type  and  their  character,  as  yet  indeterminate,  dif- 
fer only  by  almost  imperceptible  modifications,  and  which  it  is  not  pos- 
sible to  trace  out  in  full  detail.  Subject  to  the  same  functions  and 
wants,  their  isolated  and  individual  existence  fails,  as  yet,  to  reveal 
the  sympathetic  relations  that  are  in  the  end  destined  to  establish  Be- 
tween them  a  state  of  reciprocal  dependence.  Subjects  of  the  same 
kind  of  diseases,  they  are  principally  liable  to  the  convulsive  affec- 
tions, and  especially  to  inflammation  of  the  brain,  because  the  head, 
which  in  infancy  has  a  proportional  size  greater  than  in  any  other  age, 
is  in  them  a  vital  center,  towards  which  almost  all  the  efforts  of  the 
organisms  are  directed. 

"  The  shades  of  difference  in  the  sexes  soon  assume  a  more  decided 
tone,  and  their  peculiar  characteristics  become  so  much  the  more 
marked  as  the  development  of  each  individual  is  more  perfect  and 
approaches  more  nearly  to  the  period  when  by  a  sudden  change  nature 
reveals  the  completion  of  those  preparations  she  has  been  silently 
making. 

"The  interval  between  the  tenth  year  and  the  age  of  puberty  is  a 
period  of  transition,  a  sort  of  passage  from  childhood  to  adolescence, 
which  appears  to  be  the  happiest  era  in  the  life  of  a  female.  Her  ex- 
treme nervous  mobility  prevents  her  being  too  deeply  impressed  by 
the  grave  sentiments  that  might  be  fitted  to  interfere  with  her  happi- 
ness. As  this  stage  is  for  young  women  the  period  of  gentle  pleasures 
and  of  the  most  unrestrained  gaiety,  it  follows  that  imagination  ex- 
hibits every  object  under  the  most  attractive  colors,  and  that  the  exist- 
ence of  young  females  is  agreeably  varied  by  a  piquant  freedom  of 
action  and  a  great  mobility  of  tastes  and  affection.  Exempt,  at  this 
age,  from  cares  and  troubles,  they  sing,  they  weep  and  laugh  at  the 
same  moment;  and,  as  their  joys,  so  their  pleasures  and  their  griefs, 
as  well  as  all  their  impressions,  are  ephemeral;  they  proceed  along  a 
flowery  path  up  to  the  age  when  nature  calls  on  them  for  the  tribute 
which  they  owe  to  the  species. 

"The  young  girl  who,  until  now,  was  an  equivocal  non-sexual 
creature,  becomes  a  woman  in  her  countenance  and  in  all  the  parts  of 


14  KING'S  KcLKtTir  OBSTETRICS. 

her  body:  in  the  elegance  of  her  stature  and  beauty  of  her  form  ;  tin 
delicacy  of  her  features;  in  her  constitution,  in  the  sonorous  and  me- 
lodious tones  of  her  voice,  in  her  sensibility  and  affections,  in  her  char- 
acter, her  inclinations,  her  tastes,  and  even  in  her  maladies.  Very 
soon  all  the  tracts  of  resemblance  between  the  two  sexes  are  found  to 
be  effaced.  The  bud  newly  expanded  blossoms  among  the  flowers, 
and  tli is  brilliant  metamorphosis  is  signalized  by  the  rosy  tints  of  the 
cheeks  and  lips,  and  the  perfect  development  which  discloses  the* 
arrival  of  the  age  of  puberty. 

"This  important  period,  this  first  moment  of  triumph,  in  which 
nature  seems  to  renew  herself,  is  announced  by  a  sentiment  of  neces- 
sity to  multiply,  within — the  principle  of  life — and  by  various  striking 
and  admirable  phenomena  which  put  an  end  to  the  social  inertia,  in 
which  the  young  girl  has  lived  from  the  period  of  her  birth.  The 
sexual  system  soon  becomes  a  centre  of  fluxion;  nature  makes  great 
efforts  to  establish  the  periodical  discharge,  and  the  whole  machine, 
in  its  inmost  recesses,  experiences  a  succession,  a  violent  commotion, 
a  general  movement.  The  new  energy  of  the  womb  imparts  a  pow- 
erful impulse  to  the  entire  system  of  organs:  their  functions  become 
more  active ;  the  body  grows  rapidly  ;  the  various  portions  of  the  figure 
become  more  expressed  and  bring  out  those  graceful  contours,  that  be- 
long to  the  tender  sex  alone.  At  the  same  time  other  important  changes 
take  place:  the  pelvis  and  the  sexual  organs,  which  were  in  a. merely 
rudimental  condition,  now  acquire  their  full  proportions;  the  throat 
rises  and  becomes  more  sensitive ;  the  breasts  become  rounded  and  full, 
while  they  establish  their  correspondence  of  sympathy  with  the  womb. 
The  mons  veneris  comes  into  complete  relief,  and  clothes  itself  with  a 
thick  down,  which,  like  a  veil  covering  the  organs  of  modesty,  seems 
to  announce  that  they  are  destined  soon  to  become  fitted  to  act  the 
important  part  assigned  to  them  by  the  law  of  nature.  The  meshes 
of  the  cellular  tissue,  becoming  rapidly  filled  under  the  influence  of 
the  uterine  irradiation,  soon  impart  to  the  surface  of  the  body  a  volup- 
tuous embonpoint,  which  lends  the  highest  splendor  to  the  attractive 
freshness  and  beauty  of  youth. 

"  The  physiognomy  of  the  young  woman  has  now  acquired  a  new 
expression:  her  gestures  bear  the  stamp  of  her  feelings;  her  language 
has  become  more  touching  and  pathetic;  her  eyes,  full  of  life  but 
languishing,  announce  a  mixture  of  desires  and  fears,  of  modesty 
and  love  —  in  fine,  every  thing  conspires  to  excite,  to  caress,  and  to 
incite. 


WOMAN.  15 

"Her  tastes,  her  enjoyments,  and  her  inclinations  are  likewise 
modified;  her  most  pressing  want  is  to  experience  frivolous  emotions; 
she  is  passionately  given  to  the  dance,  to  show  and  to  company;  the 
curiosity  so  natural  to  her  sex  acquires  new  force  and  activity;  she 
devours  books  of  romance,  or,  niore  than  ever  fervent  in  devotion,  is 
excited  by  the  expansive  passions,  and  particularly  by  religious  piety, 
which  is  to  her  a  sort  of  love. 

"  At  this  brilliant  period  of  life,  her  moral,  which  depends  upon 
her  physical  condition,  undergoes  great  mutations.  The  young  girl 
becomes  more  tender-hearted,  niore  sensitive,  more  compassionate,  and 
appears  to  attach  herself  to  every  thing  about  her.  The  new  sensa- 
tions arising  within  her  soul  make  her  timid  in  approaching  the  com- 
panions of  her  childhood;  a  strange  trouble,  a  sort  of  restlessness  and 
agitation  before  unknown,  are  the  heralds  of  a  power  whose  existence 
she  does  not  even  suspect. 

"The  action  of  the  new  forms  of  vitality  established  within  the 
sexual  organs  augments  more  and  more,  and  reacts  with  energy  upon 
the  whole  system.  Under  the  sympathetic  irradiations  of  the  uterus 
the  general  sensibility  becomes  changed  and  even  excited  in  a  peculiar 
manner.  A  new  sentiment  soon  gives  rise  to  desires  which,  as  yet, 
have  no  definite  object,  and  to  vague  emotions,  of  an  instinct  that 
seeks  some  object — it  knows  not  what.  This  rising  want  produces 
the  impression  of  a  touching  melancholy,  a  charming  bashfulness, 
whose  principle  is  founded  in  ingenious  love  presaging  new  disposi- 
tions, and  announcing  that  the  inclinations  and  habits  of  childhood 
are  exchanged  for  other  sentiments.  The  young  virgin  becomes  timid, 
reserved,  abstract,  and  dreaming.  She  sighs  less  for  pleasure  than  for 
happiness;  the  necessity  of  loving  makes  her  seek  solitude;  and  this 
new  want,  that  troubles  her  heart  and  engages  it  wholly,  becomes,  if 
it  remains  unsatisfied,  a  source  of  multiplied  disorders  and  derange- 
ments." 

Thus  I  have  ventured  to  introduce  the  career  of  woman  —  the  ob- 
jective feature  of  the  art  and  science  of  midwifery.  The  next  step 
will  be  to  depict  the  anatomical  and  physilogical  peculiarities  of  such 
parts  of  the  female  organism  as  are  essential  to  reproduction.  It  is 
said,  that  the  boy  is  the  father  of  the  man  :  and  with  more  propriety  it 
might  be  declared  that  the  girl  is  the  mother  of  the  woman.  The  doll 
is  the  ideal  representative  of  the  race. 


16 


KING'S    ECLECTIC    OBSTETRICS. 


OH  A  I'TKR    II. 

THE  PELVIS:  "TRUE"  AND  "  FALSE" — DIFFERENCE  BETWEEN  MALE 
AND  FEMALE  PELVIS:  PELVIC  ARTICULATIONS,  ETC. 

THE  PELVIS,  so  named  from  its  fancied  resemblance  to  an  an- 
cient basin,  is  a  bony  ring-like  structure,  of  conical  shape,  with  the 
base  directed  upward;  situated  between  the  last  lumbar  vertebra  and 
the  lower  extremities,  receiving  the  weight  of  the  body  above,  trans- 
mits it  to  the  lower  limbs.  It  is  formed  by  the  union  of  four  bones — 
viz:  the  two  Ossa  Innominate,  the  Sacrum,  and  the  Coccyx.  It  is 
divisible  into  two  parts  or  cavities,  an  upper  and  a  lower,  the  dividing 
line  being  the  liiica  ilio  pcctinea.  The  upper  portion  is  the  larger,  or 
False  Pelvis,  formed  solely  by  the  alae  ilia.  The  lower  is  the  smaller, 
or  True  Pelvis,  formed  by  the  sacrum,  ilium,  pubis,  and  ischium. 

FIG.  2. 


ADULT  MALE  PELVIS. 

The  SACRUM  is  situated  on  the  superior-posterior  part  of  the 
pelvis,  immediately  below  the  last  lumbar  vertebra,  with  which  its 
superior  surface  articulates,  above  the  os  coccyx,  and  between  the  two 
ossa  innominata,  to  each  of  which  it  is  united  by  means  of  ligaments. 
It  is  a  large  bone,  pyramidal  or  triangular  in  shape,  the  base  being 


THE    PELVIS. 


17 


upward ;  its  anterior  face  is  smooth  and  concave,  and  its  posterior 
irregular  and  convex.  The  concavity  of  its  interior  face  is  from  above 
downward,  and  its  depth,  in  a  well-formed  pelvis,  is  such,  that  a  per- 
pendicular let  fall  from  a  line,  drawn  from  the  apex  to  the  base  of  the 
bone,  upon  the  deepest  point  of  the  concavity,  will  measure  from  nine 
to  twelve  lines,  or  from  three-quarters  of  an  inch  to  an  inch;  this  con- 
cavity is  termed  the  hollow  of  the  sacrum;  it  may,  however,  vary  very 
much,  and  when  too  strait  or  too  much  curved,  it  presents  an  obstacle 
to  the  easy  passage  of  the  child's  head  through  the  excavation. 

FIG.  3. 


A.  The  Sacrum. 

B.  The  Os  Coccyx. 

C  C.   The  Two  Iliac  Bones. 
D  D.  The  Two  Pubic  Bones. 
E  E.  The  Two  Ischiatic  Bones. 
1  1.     The  Crest  of  the  Ilium. 


ADULT  FEMALE  PELVIS. 

2  2. 


The    Anterior-superior    Spinous   processes 
of  the  Ilia. 

3  3.    The  Acetabula  or  Cotyloid  Cavities. 

4  4.    The  Tuberosities  of  the  Ischia. 

5  5.    The  Obturator  Foramina. 

6.    The  Promontory  of  the  Sacrum. 


During  childhood,  the  os  sacrum  is  composed  of  five  distinct  pieces, 
termed  false  vertebrae,  which  become  firmly  consolidated  at  adult  age, 
and  leave  five  surfaces  nearly  quadrilateral,  and  which  are  separated 
from  each  other  by  four  projecting  transverse  seams  or  ridges,  at  the 
original  points  of  separation.  At  the  sides  or  lateral  portions  of  these 
seams,  are  a  series  of  openings,  termed  foramina,  usually  four  on  each 
side,  which  terminate  outwardly  in  large  grooves  converging  to  each 
other,  and  which  are  named  the  anterior  sacral  foramina  and  grooves^ 
2 


18  KING'S  ECLECTIC  OBSTETRICS. 

and  which  serves  to  lodge  and  transmit  the  sacral  nerves  coming  from 
the  spinal  canal.  The  nervous  cords  lying  in  these  shallow  grooves 
are  comparatively  secure  from  injurious  pressure  during  labor,  yet  it 
is  sometimes  the  case,  that  during  the  passage  of  the  child's  head,  these 
sacral  nerves  are  exposed  to  much  pressure,  which,  as  in  other  instances 
of  compression  upon  a  nerve,  occasions  a  numbness,  pain  or  severe 
<-ramps  in  the  parts  to  which  they  are  distributed,  as  in  the  thigh,  leg, 
or  foot.  This  usually  ceases  as  soon  as  the  pressure  is  relieved  by  the 
expulsive  progress  of  the  head,  but  when  the  nerves  have  been  severely 
bruised  or  compressed,  the  unpleasant  effects  may  remain  for  some  time 
after  delivery. 

External  to  these  sacral  foramina,  and  on  the  projecting  cristae, 
which  separate  the  grooves,  arise  the  asperities,  which  serve  as  points 
of  attachment  to  the  fibers  of  the  pyriform  muscles. 

The  posterior  surface  of  the  sacrum  is  convex  from  above  down- 
ward, rough  and  unequal,  presenting  on  the  median  line,  four  emi- 
nences or  spinous  processes,  which  decrease  in  size  as  they  descend; 
on  either  side  of  these  eminences,  there  are  four  openings  or  forimina, 
smaller  than  those  on  the  anterior  surface,  which  are  named  the  pos- 
terior sacral  foramina,  and  which  transmit  the  posterior  branches  of 
the  sacral  nerves.  External  to  these  foramina  are  a  number  of  pro- 
cesses, which  serve  as  points  of  attachment  to  several  muscles  and 
ligaments. 

The  lateral  surfaces  of  the  sacrum  are  rough,  thick  above,  but 
diminishing  as  they  descend,  and  in  the  recent  subject  are  covered 
with  cartilage,  which  unites  them  to  the  iliac  bones.  The  superior 
portion  of  each  lateral  surface,  which  articulates  with  the  ilium,  is 
broad  and  irregular;  and  the  inferior  edges, are  thin  and  nearly  sharp, 
and  give  attachments  to  the  greater  and  lesser  sacro-sciatic  ligaments. 

The  base  of  the  sacrum  is  about  two  and  a  half  inches  thick,  and 
about  four  inches  in  breadth  and  articulates  with  the  last  lumbar  ver- 
tebra in  such  a  manner,  as  to  form  a  projection  at  the  superior  strait, 
called  the  promontory  of  the  sacrum  or  the  sacro^vertebral  angle.  At 
the  posterior  surface  of  the  base,  is  a  triangular  aperture,  which  is  the 
commencement  of  a  canal,  traversing  the  whole  extent  of  the  sacrum, 
which  gradually  diminishes  in  size  as  it  descends,  and  in  which  the 
spinal  cord  is  continued.  The  apox  of  the  sacrum  is  small,  having  an 
oval  surface  which  articulates  with  the  base  of  the  coccyx. 

The  texture  of  the  sacrum  is  spongy  and  cellular,  and  covered  ex- 
ternally by  a  thin  lamina  of  compact  tissue ;  its  length  is  about  four 


THE    PELVIS.  19 

and  a  half  inches.  The  union  of  the  sacrum  with  the  ilia  is  so 
arranged  as  to  give  great  firmness  and  security  to  its  position,  so  that 
it  may  sustain  without  injury,  any  Weight  from  within  outward,  and 
from  above  downward  ;  the  sacrum  entering  the  ilia  like  a  wedge, 
having  its  superior  portion  broader  than  its  inferior,  and  its  anterior 
point  of  union  broader  than  its  posterior. 

The  OS  COCCYX  or  cuckoo  bone,  so  named  from  its  resemblance 
to  the  beak  of  the  cuckoo,  is  the  caudal  extremity  of  the  spinal  column. 
It  is  a  small,  single,  triangular  bone,  the  base  of  which  points  upward, 
and  unites  with  the  apex  of  the  sacrum  by  means  of  an  oval  articular 
surface,  which,  it  is  said,  admits  of  a  backward  motion  of  the  coccyx, 
when  pressed  by  the  fetal  head,  to  the  extent  of  half  an  inch.  Yet 
the  firmness  by  which  the  coccyx  is  fastened  to  the  ischia,  through 
means  of  the  saero-sciatic  ligaments,  is  unfavorable  to  any  such  mo- 
bility, except  by  severe  and  continued  pressure.  The  coccyx  is  flat- 
tened, curved  from  behind  forward,  and  bears  some  resemblance  to  the 
sacrum,  though  it  differs  from  it  in  being  much  smaller,  about  one  and 
a  half  inches  in  length,  and  in  having  no  spinal  canal.  Its  anterior 
surface  is  slightly  concave  and  rough,  and  supports  the  lower  extremity 
of  the  rectum  ;  its  posterior  surface  is  convex  and  unequal,  is  separated 
from  the  skin  only  by  the  posterior  sacro-coccygeal  ligament,  and  has 
inserted  into  it  some  of  the  fibers  of  the  gluteeus  magnus  muscle.  Its 
lateral  edges  are  rough,  giving  attachment  to  the  small  sciatic  liga- 
ments and  the  ischio-coccygeus  muscle.  Its  apex,  generally  project- 
ing in  front,  gives  attachment  to  the  fibers  of  the  external  sphincter 
ani  muscle.  In  childhood  the  coccyx  is  formed  of  three  or  more  bony 
pieces,  but  which  become  consolidated  in  adult  age.  The  internal 
structure  of  this  bone  is  cellular,  and  covered  externally  by  a  very 
delicate  lamina  of  compact  texture.  It  is  called  by  the  various  names 
of  buckle,  knuckle,  or  whistle  bone,  crupper  bone,  etc. 

The  OSSA  INXOMINATA,  or  nameless  bones,  and  sometimes 
termed  the  haunch  bones,  are  two  in  number;  they  are  the  largest  and 
most  irregular  of  the  pelvic  bones,  are  of  a  quadrilateral  form,  con- 
tracted in  their  central  portions,  and  form  the  lateral,  anterior,  and  in- 
ferior portions  of  the  pelvis.  Each  one  of  these  bones  consists,  in 
early  childhood,  of  three  distinct  pieces,  but  which  become  firmly  con- 
solidated in  the  adult.  These  are  called  the  os  ilium,  the  os  ischium, 
and  the  os  pubis,  whose  union  takes  place  in  the  acetabulum  or  cotyloid 


20  KING'S  ECLECTIC  OBSTETRICS. 

cavity;  the  dividing  lines  of  these  three  bones  meet  nearly  in  the 
center  of  the  aectabulum,  giving  the  upper  and  outer  two-fifths  to  the 
ilium,  anteriorly  one-fifth  to  the  pubis,  and  the  remaining  two-fifths 
to  the  ischium  ;  these  several  bones  entering  into  the;  formation  of  the 
acetabulum.  For  purposes  of  description,  and  as  a  matter  of  more 
easy  reference,  the  above  division  is  preserved  by  anatomists. 

The  OS  ILIUM,  hip  or  coxal  bone  (one  on  each  side  of  the  sacrum, 
and  which  form  the  upper  and  lateral  portions  of  the  pelvis),  is  the 
largest  bone  of  the  os  innominatum,  is  flat,  broad,  and  nearly  triangular 
in  shape.  The  base  or  body  of  the  bone  is  situated  at  the  thick  and 
narrow  part  which  forms  the  upper  portion  of  the  acetabulum,  and  the 
large  expansion  or  wing  which  passes  from  it,  upward  and  outward,  is 
termed  the  ala,  and  which  aids  in  forming  the  cavity  of  the  false  pelvis. 
The  external  or  femoral  surface  of  the  ilium  is  convex,  and  is  called 
the  dorsum  il'd  or  gluteal  region,  having  the  three  glutei  muscles  lying 
upon  it ;  and  presents  below,  in  its  inferior  and  outer  part,  a  cavity 
for  the  head  of  the  femur,  called  the  acetabulum  or  cotyloid  cavity. 

The  internal  or  abdominal  portion,  called  the  ventor  or  costa  presents 
at  the  upper  part  a  broad,  smooth,  concave  surface,  termed  the  internal 
iliac  fossa,  on  which  the  internal  iliac  muscle  is  situated,  and  which 
likewise  supports  the  large  intestine;  in  one  of  these  fossae,  the  child's 
head  is  placed  during  the  operation  of  turning.  Below,  is  a  prominent 
ridge  or  curved  line,  running  from  behind  forward,  that  is,  from  the 
superior  part  of  the  sacro-iliac  junction  to  the  top  of  the  pubis,  forming 
part  of  the  lined  ilio-pectinea,  or  ttio-pubic  line  which  defines  the 
superior  strait.  The  excavation  above  this  ridge,  which  is  also  named 
the  brim  of  the  pelvis,  is  termed  the  false,  upper,  or  superior  basin  or 
pelvis,  while  the  cavity  below  is  termed  the  true,  lesser,  or  lower  basin 
or  pelvis,  or  the  pelvic  cavity. 

The  superior  or  upper  convex  edge  of  each  wing,  is  called  the  crest, 
or  crista  of  the  ilium,  and  to  which  the  principal  muscles  of  the  ab- 
domen that  are  called  into  action  during  labor  are  attached,  as  the  in- 
ternal and  external  oblique,  and  the  transversalis ;  this  crest  is  rough 
and  thick,  for  the  insertion  of  muscles,  is  shaped  like  the  letter/,  being 
thicker  in  front  and  behind  than  in  the  middle,  and  terminates  in 
front,  in  an  anterior-superior  spinous  process,  from  which  some  of  the 
muscles  of  the  abdomen  and  thigh  arise,  and  into  which  others  are  also 
inserted — and  behind,  in  a  posterior-superior  spinous  process,  under- 
neath each  of  which  processes  is  a  semi-circular  notch,  terminating 


THE    PELVIS.  21 

inferiorly  in  an  anterior  and  &  posterior-inferior  spinous  process  ;  all  of 
which  processes  serve  as  points  of  origin  and  insertion  of  muscles  and 
ligaments.  The  surface  which  articulates  with  the  sacrum  is  rough 
and  irregular.  Immediately  below  the  posterior-inferior  spinous  pro- 
cess is  an  arched  sinuosity,  forming  at  the  union  of  the  ilium  and  sacrum 
the  great  sciatic  notch,  which  is  two  inches  in  depth,  and  terminates 
inferiorly,  by  an  acute  and  sharp  spinous  process  called  the  spine  of 
the  ischium;  which  points  backward  and  slightly  inward. 


The  OS  ISCHIUM,  os  sedentarium,  or  seat  bone,  occupies  the 
lower  part  of  the  pelvis  ;  its  base  or  body  forms  the  inferior  portion 
of  the  cotyloid  cavity,  and  is  very  thick  and  strong.  The  internal 
surface  of  this  bone  is  smooth  and  slightly  concave,  and  is  called  the 
plane  of  the  ischium;  it  is  nearly  an  equilateral  triangle,  and  is  three 
•and  a  half  inches  in  length.  The  planes  of  the  two  opposite  ischia 
incline  toward  each  other,  forward  and  downward,  and  which  conver- 
gence exerts  an  influence  on  the  fetal  head  during  labor,  repelling  or 
deflecting  the  vertex  toward  the  pubic  arch,  as  the  head  approaches 
the  outlet  of  the  pelvis. 

The  spine  of  the  ischium,  proceeding  from  the  posterior  portion  of 
the  os  ischium,  furnishes  a  place  of  attachment  for  the  lesser  sacro- 
ischiatic  or  sacro-sciatic  ligament;  beneath  this  process  is  a  concavity 
or  no-tch,  named  the  lesser  ischiatic,  or  sciatic  notch  in  which  the  tendon 
of  the  obturator  interims  plays.  Below  this,  is  the  inferior  or  lower 
portion  of  the  ischium,  or  that  part  upon  which  the  body  rests  when 
in  a  sitting  posture  ;  it  is  rough,  thick,  and  strong,  and  is  termed  the 
tuberosity  of  the  ischium;  the  great  sacro-sciatic  ligament  arises  on  the 
inside  of  this  tuberosity,  and  its  outside,  inside,  and  central  surfaces 
give  origin  to  various  muscles. 

Passing  obliquely  from  without  inward,  and  from  below  upward, 
from  the  tuberosity  of  the  ischium,  is  a  flat  process  of  bone  called  the 
ramus  of  the  ischium,  which  unites  with  the  descending  branch  or 
ramus  of  the  pubis,  and  assists  in  forming  the  pubic  arch.  In  the 
female  pelvis,  the  anterior  edge  of  this  ramus  is  beveled  or  turned 
outward,  thus  affording  more  space  for  the  passage  of  the  fetal  head 
under  the  pubic  arch.  The  opening  in  the  anterior  part  of  the  pelvis, 
formed  by  the  ischium  and  os  pubis,  is  called  the  thyroid,  sub-pubic, 
or  obturator  foramen,  through  which  pass  the  obturator  vessels  and 
nerves,  and  to  its  inner  side  is  attached  the  adductors  and  the  obturator 
externus.  This  foramen  is  rounded  in  man  and  triangular  in  woman. 


22  KINt.'s    ECLECTIC  OBSTETRICS. 

The  OS  PUBIS,  otherwise  variously  called  the  .shear  bone,  the 
cross  bone,  the  bar  bone,  or  pecten,  is  situated  at  the  inner  and  an- 
terior part  of  the  os  innominatum,  and  is  joined  to  its  fellow  of  the 
opposite  side,  by  a  union  or  articulation  termed  the  symphysis  pubi*. 
It  may  be  divided  into,  the  body,  a  horizontal,  and  a  descending 
ram  us  or  branch.  The  body,  or  base,  of  each  os  pubis  is  placed  trans- 
versely before  the  anterior  part  of  the  ilium  ;  and  from  the  side  of  the 
body  proceeds  the  horizontal  ramus,  going  outward  to  meet  the  ilium. 
The  superior  face  of  the  os  pubis  is  flat,  and  upon  its  outer  and  an- 
terior portion  is  its  spiuous  process,  which  gives  attachment  to  Pou- 
part's  ligament,  and  from  this  process  two  eminences  proceed,  one  pass- 
ing outward  to  be  lost  in  the  acetabulum ;  the  other,  running  along  the 
inner  margin  of  the  horizontal  ramus,  is  called  the  crest  of  the  pubis, 
or  crista  pubis.  This  ridge  is  sharp  and  elevated,  and  forms  the  an- 
terior third  of  the  linea  ilio-pectineal  eminence.  The  descending 
ramus  of  the  pubis  passes  downward  to  unite  \yith  the  ascending  ramus 
of  the  ischium.  As  with  the  rami  of  the  ischia,  the  anterior  edges  of 
the  pubic  rami  are  beveled  or  turned  outward,  affording  a  sufficiently 
large  and  free  opening  for  the  fetal  head  to  pass.  The  descending 
ramus  is  connected  with  its  fellow  of  the  opposite  side,  toward  their 
origin,  by  a  ligamentous  substance,  called  the  triangular  ligament, 
which  is  a  part  of  the  interpubic  ligament,  binding  the  two  tubes  to- 
gether, and  rendering  the  arch  of  the  pubis  broader  or  lower,  and  also 
stronger.  The  arch  of  the  pubis  is  formed  on  the  anterior  and  inferior 
part  of  the  pelvis,  by  the  union  of  the  two  pubic  rami ;  it  is  much 
wider  in  the  female  than  in  the  male.  . 

The  anterior  face  of  the  body  of  the  os  pubis  is  concave  and  rough, 
for  the  origin  of  the  adductor  muscles  of  the  thigh ;  its  posterior  sur- 
face is  nearly  flat  and  smooth,  but  contributing  a  little  to  favor  the 
general  concavity  of  the  pelvis.  The  largest  or  thickest  portion  of  the 
pubic  bone  is  that  employed  in  the  formation  of  the  acetabulum;  the 
next  thickest  portion  is  at  the  symphysis  pubis,  from  which  it  becomes 
gradually  thinner  as  it  extends  toward  the  obturator  foramen. 

It  will  be  seen  that  the  ilium  forms  no  portion  of  the  inferior  strait,, 
but  enters  largely  into  the  superior— also  that  the  ischium  forms  no 
portion  of  the  superior  strait,  but  only  of  the  inferior — while  the 
pubic  bones  form  a  large  portion  of  both  straits.  Hence  a  deformity 
of  the  ilium  would  affect  only  the  brim,  or  the  false  pelvis ;  a  deformity 
of  the  ischium  would  implicate  only  the  outlet;  but  a  distorted  pubes 
would  necessarily  involve  each  of  the  straits. 


SYMYHYSES    AND    LIGAMENTS    OF    THE    PELVIS.  23 


CHAPTER    III. 

SYMPHYSES    AND    LIGAMENTS    OF    THE    PELVIS.     ' 

THE  BONES  of  the  PELVIS  are  united  together  in  such  a  man- 
ner as  to  give  to  it  great  strength,  the  articulations  being  effected  by 
means  of  ligaments  and  the  interposition  of  cartilage  giving  support 
to  the  trunk  and  favoring  the  movements  of  the  lower  extremities. 
The  joints  to  be  considered — which  have  received  the  name  of  Sym- 
physes:  each  symphysis  being  designated  according  to  the  bones  which 
form  it — are,  the  symphysis  pubis,  the  two  sacro-iliac  symphyses,  the 
sacro-coccygeal  symphysis,  and  the  lumbo-sacral  or  sacro-vertebral 
symphysis.  They  all  belong  to  the  class  of  joints  termed  amphiar- 
throdial. 

The  SYMPHYSIS  PUBIS,  or  pubic  articulation,  is  formed  by  the 
junction  of  the  oval  articular  surfaces  between  the  bodies  of  the 
ossa-pubis.  A  thick  layer  of  tough  fibro-cartilage  is  firmly  united  to 
the  articulating  surface  of  each  pubic  bone;  this  passes  across  from 
one  bone  to  the  other,  and  is  so  strong  as  to  admit  rather  of  the  dis- 
ruption of  the  bone  than  of  its  own  tissue.  At  the  center  of  the  sym- 
physis, and  toward  the  posterior  third  of  the  fibro-cartilage,  are  two 
smooth,  polished,  oblong  articular  surfaces,  covered  by  a  cartilage, 
and  lined  by  a  synovial  membrane,  which  arrangement  is  difficult  to 
detect  in  man,  or  even  in  woman,  except  when  she  has  died  shortly 
previous  to,  or  soon  after,  parturition. 

Some  authorities  doubt  the  existence  of  a  synovial  membrane  in 
the  pubic  joint.  The  ligaments  which  strengthen  the  pubic  articula- 
tion are  four  in  number:  1,  the  anterior  pubic  ligament,  lying  on  the 
anterior  face  of  the  symphysis  pubis ;  2,  the  posterior  pubic  ligament, 
which  is  an  expansion  of  the  periosteum;  3,  the  superior  pubic  liga- 
ment, or  supra-pubic  ligament,  which  supports  the  superior  edge  of  the 
pubis,  and  effaces  all  its  inequalities;  and  4,  the  inferior,  or  sub-pubic 
ligament,  which  is  remarkably  strong  and  thick,  and  of  a  triangular 
form;  by  some,  it  is  considered  as  a  continuation  of  the  inter-pubic 
ligament.  It  adds  greatly  to  the  strength  of  the  articulation,  and  its 
inferior  edge  constitutes  the  crown  of  the  pubic  nrcJi. 


24  KING'S  ECLECTIC  OBSTETRICS. 

The  SACRO-ILIAC  SYMPHYSIS,  or  junction,  is  the  articulation 
formed  by  the  corresponding  rough  surfaces  of  the  sacrum  and  ilium, 
and  of  which  there  are  two — one  on  the  right,  and  the  other  on  the  left 
superior  lateral  portion  of  the  sacrum.  Each  of  these  articulating  sur- 
faces has  a  covering  of  cartilage,  which  is  thicker  on  the  sacrum  than 
on  the  ijia,  and  between  which  exists  a  thick,  yellowish  fluid,  which 
serves  to  lubricate  the  parts;  and  in  children  and  pregnant  women 
there  is  said  to  be  a  synovial  membrane  in  each  joint. 

The  ligaments  which  aid  in  strengthening  this  articulation,  are 
four  in  number:  1.  The  posterior  sacro-iliac  ligament  fills  nearly  the 
whole  of  the  deep  excavation  comprised  between  the  sacrum  and  the 
two  posterior  spinous  iliac  processes;  their  union  constitutes  a  pyra- 
midal ligament,  capable  of  immense  resistance.  This  ligament  arises 
from  the  posterior  and  inferior  spinous  processes  of  the  ilium,  and 
from  the  margin  of  the  sacrum  and  coccyx,  and  passes  outward  and 
downward  to  be  inserted  into  the  tuberosity  of  the  ischium;  it  is  broad 
at  its  origin,  but  narrow  and  thick  at  its  insertion.  2.  The  anterior 
sacro-iliac  ligament,  which  extends  transversely  from  the  sacrum  to  the 
ilium,  is  an  expansion  of  the  periosteum  of  the  pelvis,  which  passes 
in  front  of  the  articulation,  and  adheres  to  it  but  feebly.  3.  The 
superior  sacro-iliac  ligament,  which  passes  transversely  from  the  base 
of  the  sacrum  to  the  ilium,  is  very  thick  and  strong.  4.  The  infe- 
rior sacro-iliac  ligament  arises  from  the  posterior-superior  spinous 
process  of  the  ilium ;  its  superior  fibers  being  inserted  below  the  third 
sacral  foramen,  while  the  lower  portion  is  inserted  anteriorly  into  the 
tubercle  of  the  extremity  of  the  edge  of  the  sacrum,  and  posteriorly  to 
the  great  sacro-sciatic  ligament. 

The  foregoing  articulations  are  still  further  strengthened  by  the 
following  ligaments,  which  pass  between  the  sacrum  and  ischium,  and 
which  assist  in  completing  the  parieties  of  the  pelvic  cavity — viz.  :  1. 
The  posterior,  or  greater  sacro-sciatic  ligament,  which  arises  from  the 
internal  lip  of  the  tuberosity  of  the  ischium,  and  from  its  ascending 
ramns;  it  is  situated  obliquely  in  the  posterior-inferior  part  of  the 
pelvis,  is  contracted  in  its  center  and  expanded  at  its  extremities,  and 
passes  upward  and  backward  to  be  inserted  into  the  margin  of  the 
coccyx  and  sacrum,  and  into  the  posterior-inferior  spinous  process  of 
the  ilium.  2.  The  anterior,  or  lesser  sacro-sciatic  ligament,  is  placed  in 
front  of  the  greater  sacro-sciatic  ligament,  which  it  crosses;  it  arises 
from  the  free  margin  of  the  sacrum  and  from  all  the  bones  of  the 
coccyx,  and  is  inserted  into  the  summit  of  the  spine  of  the  ischium. 


SYMPHYSES    AND    LIGAMENTS    OF    THE    PELVIS.  25 

These  two  ligaments  convert  the  great  sciatic  notch  into  two  openings 
or  foramina;  the  upper  foramen  is  the  larger,  irregularly  oval,  and 
transmits  the  pyriformis  muscle,  the  great  sciatic  nerve,  gluteal,  ischi- 
atic  and  internal  pudic  vessels  and  nerves,  while  the  lower  foramen  is 
of  a  long  triangular  shape,  and  gives  passage  to  the  internal  obturator 
muscle  and  internal  pudic  vessels  and  nerves. 

The  obturator,  or  sub-pubic  ligament,  may  likewise  be  mentioned ; 
it  is  inserted  by  its  internal  semi-circumference  to  the  posterior  face 
of  the  ascending  ischiatic  ram  us,  and  by  its  external  semi-circumfer- 
ence to  the  outline  of  the  obturator  foramen.  This  ligament  (doses 
the  obturator  foramen,  with  the  exception  of  an  opening  at  its  upper 
part,  through  which  pass  the  obturator  vessels  and  nerves.  The  obtu- 
rator muscles  are  attached  to  the  two  surfaces  of  this  membrane.  ' 

The  SACRO-COCCYGEAL  SYMPHYSIS  is  the  articulation  be- 
tween the  apex  of  the  sacrum  and  the  base  of  the  coccyx;  it  is  similar 
to  the  joints  between  the  bodies  of  the  vertebrae.  The  union  is  effected 
by  two  ligaments,  and  strengthened  by  an  inter  articular  jibro-cartilage. 
1.  The  anterior  sacro-coccygeal  ligament,  which  arises  from  the  inferior 
extremity  of  the  sacrum,  extends  over  the  whole  anterior  face  of  the 
coccyx,  becoming  blended  with  the  periosteum.  2.  The  posterior  sacro- 
coccygeal  ligament,  which  arises  from  the  last  sacral  bone,  is  inserted 
into  the  posterior  surface  of  the  second  bone  of  the  coccyx.  This 
ligament  closes  in  and  completes  the  lower  and  back  part  of  the  sacral 
canal. 

The  Jnterarticular  Fibro-cartilage,  interposed  between  the  articu- 
lating surfaces  of  the  sacrum  and  coccyx,  differs  from  the  ordinary 
intervertebral  cartilage  in  that  it  is  thinner  and  firmer;  it  assists  in 
maintaining  the  connection  between  the  bones,  rendering  mobility,  it 
is  claimed  by  some  authors,  impossible.  This  joint  is  undoubtedly 
subject  to  slight  motion  under  certain  circumstances,  which  will  be 
noticed  further  along  in  the  work. 

There  are,  in  early  life,  coccygeal  articulations  which  unite  the 
several  pieces  of  the  coccyx  with  each  other;  their  consolidation  takes 
place  more  rapidly  in  males  than  in  females. 

LUMBO-SACRAL  SYMPHYSIS  is  formed  by  the  articulation  of 
the  fifth  lumbar  vertebra  with  the  upper  surface  of  base  of  the  sacrum. 
The  oblique  position  of  the  bones  forming  this  articulation  results 
in  a  projection  anteriorly,  at  the  superior  strait,  called  the  promon- 


26  KING'S  ECLECTIC  OBSTETRICS. 


tory  of  1li<-  Min-tnii,  or  the  ^aero-vertebral  angle.  The  ligaments  of  this 
articulation,  in  addition  to  those  commonly  existing  between  the  ver- 
tebne,  are  two  in  number:  1.  The  lumbo-aacral  ligament  passes  from 
the  lower  j)ortion  of  the  transverse  process  of  the  last  lumbar  vertebra 
to  the  lateral  portion  of  the  base  of  the  sacrum.  2.  The  lumbo-iliac 
ligament  passes  horizontally  from  the  tip  of  the  transverse  process  of 
the  last  lumbar  vertebra  to  the  crest  of  the  ilium,  covering  the  sacro- 
iliac  articulation.  The  intervertebral  disk  also  contributes  to  the  for- 
mation and  straightening  of  this  joint,  which  is  one  of  the  strongest 
of  the  pelvis. 

The  ilio-femoral  articulation,  or  the  junction  of  the  femoral  bones 
with  the  ilia,  in  the  cotyloid  cavity,  is  a  pelvic  articulation  ;  it  bears 
no  relation  to  parturition,  however,  and  only  needs  a  passing  reference. 

MOVEMENTS  AT  THE  PELVIC  AKTICULATIONS. 

It  has  long  been  a  question  whether  the  articulations  of  the  pelvis 
are  possessed  of  any  motion.  An  examination  of  the  method  by  which 
the  bones  are  united  with  each  other,  and  the  solidity  of  their  union, 
would  lead  us  to  consider  them  as  perfectly  immovable,  at  least  in  the 
ordinary  conditions  of  life.  Yet,  when  we  reflect  that  they  are  sup- 
plied with  synovial  membranes,  which  are  only  found  in  movable  ar- 
ticulations, we  may  admit  them  to  possess,  under  certain  circumstances, 
a  slight  degree  of  motion,  as  for  instance,  the  shock  of  a  fall  from  a 
height,  upon  the  feet,  is  much  diminished  in  its  influence  upon  the 
body  and  brain,  by  a  slight  mobility.  Dr.  Laborie,  from  examinations 
of  the  pelves  of  women  shortly  after  delivery,  is  led  to  believe  that 
there  is  a  mobility  of  these  articulations  tending  to  enlarge  the  trans- 
verse diameter  at  the  outlet;  the  other  diameters  being  increased  by 
relaxation  of  the  sacro-sciatic  ligaments  and  the  mobility  of  the  sacro- 
coccygeal  symphysis;  the  sacro-iliac  and  pubic  symphyses  presenting 
characters  partaking  partly  of  enarthrosis,  and  partly  of  ginglymus. 

There  is  no  doubt,  but  that  during  pregnancy  or  parturition,  there 
may  be  a  relaxation,  or  separation  of  the  symphyses;  the  symphysis 
pubis  especially  being  more  frequently  involved  than  the  sacro-iliac 
joints  :  any  considerable  separation  however,  favoring  marked  mobility, 
is  an  uncommon  event,  and  one  which  is  seldom  met  with,  being  a 
pathological  condition  dependent  upon  some  disease  of  the  parts  them- 
selves. 

For,  were  it  a  circumstance  common  to  parturient  women,  it  would 
be  impossible  for  them  to  walk  or  exercise  immediately  previous,  as 


SYMPHYSES    AND    LIGAMENTS    OF    THE    PELVIS.  27 

well  as  subsequent,  to  confinement  (acts  which  are  accomplished  daily), 
from  the  fact  that  an  appreciable  degree  of  mobility  would  not  only 
render  it  impossible  to  walk,  but  likewise  very  painful  to  stand.  The 
tissues  about  the  joints  may,  probably,  become  softer,  and  perhaps 
more  movable  during  pregnancy  and  parturition,  yet  any  appreciable 
relaxation  or  separation  must  necessarily  be  unfavorable,  and  owe 
their  origin  to  some  disease  not  connected  with  these  conditions. 

\Vhen  relaxation  does  take  place,  the  symphyses  become  .swollen, 
and  sometimes  dilate  so  much  as  to  separate  the  bones  which  aid  in 
their  formation,  permitting  them  to  glide  over  each  other,  and  occa- 
sioning uneasiness  and  fatigue  in  the  movements  of  the  female,  with 
difficulty  of  standing.  Should  labor  come  on,  the  auxiliary  muscles 
of  the  uterus,  not  having  any  longer  a  fixed  point  of  insertion  in  the 
vacillating  bones  of  the  pelvis,  draw  the  symphyses  apart,  producing 
great  agony;  and  the  female,  dreading  the  pain  occasioned  by  their 
contraction,  remains  passive,  and  allows  the  uterus  slowrly  and  diffi- 
cultly to  expel  its  contents,  unaided  by  her  efforts.  Instances  of  this 
kind  have  taken  place,  and  have  always  proved  a  source  of  much  dis- 
tress and  suffering,  causing  more  or  less  intense  pain  on  motion,  with 
much  difficulty  in  moving  the  lower  extremities,  and  an  inability  to 
stand. 

Occasionally  there  is  not  only  a  relaxation,  but  likewise  an  actual 
separation  of  the  pelvic  joints,  giving  rise  to  most  intense  suffering, 
inflammation,  peritonitis,  and  all  the  symptoms  of  simple  relaxation 
in  a  more  aggravated  form,  greatly  endangering  life.  This  separation 
may  be  accidental,  resulting  from  the  powerful  efforts  made  by  the 
patient  to  expedite  her  delivery;  or  it  may  ensue  from  the  employ- 
ment of  the  lever  or  forceps  in  extracting  the  fetal  head.  Sometimes 
it  is  congenital,  and  usually  accompanies  exstrophy  or  extroversion  of 
the  bladder,  of  which  it  may  probably  be  the  result. 

There  is  but  little  protection  given  by  ligaments  to  the  anterior 
part  of  the  sacro-iliac  symphyses,  the  only  ligament  of  any  size  being 
the  anterior  sacro-iliac;  the, principal  ligaments  are  placed  on  the  outer 
edge  of  the  joint,  and  any  tendency  to  open  at  its  inner  margin  is  pre- 
vented by  the  ligaments  of  the  symphysis  pubis.  Hence,  a  separation 
of  the  pubic  bones  will  occasion  a  relaxation  or  separation  of  the  sacro- 
iliac  symphyses;  and  when  a  separation  takes  place  in  consequence  of 
the  pubic  junction  being  cut  or  ruptured,  the  sacro-iliac  symphyses 
immediately  open  considerably,  the  effect  of  which  is  pain,  inflamma- 
tion, and,  if  not  remedied,  caries  of  the  bone,  suppuration  of  the  partsy 
and  hectic  fever. 


•JS  KING'S   ECLECTIC  OIJKTKTRICS. 

Decided  separation  of  the  pelvic  symphyses  may  be  diagnosed  by 
carefully  examining  the  parts.  When  the  pubic  symphysis  is  involved, 
it  may  be  recognized  by  grasping  the  symphysis  between  the  thumb 
externally  and  one  or  two  fingers  within  the  vagina,  with  the  patient 
standing;  an  effort  at  walking  will  at  once  impart  the  degree  of  mo- 
bility existing  between  the  bones.  Rupture  of  the  sacro-iliac  joints 
may  be  determined  by  placing  the  open  hands  over  the  symphyses  and 
wings  of  the  ilium,  and  directing  the  patient  at  the  same  time,  to  move 
the  lower  limbs  as  in  walking;  the  degree  of  mobility  and  separation 
will  at  once  become  apparent.  Relaxation  or  rupture  of  the  pelvic 
joints  may  develop  during  the  last  months  of  pregnancy,  or  not  until 
after  labor,  and  is  always  attended  with  pain  on  the  least  exertion. 
Inflammation  is  occasionally  present,  and  may  result  in  suppuration 
and  the  evacuation  of  pus.  Locomotion  is  usually  impaired,  and  be- 
comes impossible  if  there  exists  a  decided  degree  of  separation  of  the 
symphyses. 

TREATMENT. — Rest  is  the  most  essential  factor  in  the  treatment 
of  either  relaxation  or  separation  of  the  symphyses  of  the  pelvis.  It 
will  be  absolutely  necessary  for  the  patient  to  remain  quiet,  and  in  a 
recumbent  position  for  a  long-continued  period  of  time.  The  patient 
must  not  be  permitted  to  stand  on  the  feet,  or  attempt  to  walk;  walk- 
ing, particularly,  is  likely  to  prove  injurious,  and  excite  inflammatory 
action.  Internal  medication  is  uncalled  for  in  the  treatment  of  this 
affection.  Local  agents,  to  control  inflammatory  development,  and 
anodynes  to  relieve  pain,  may  be  useful  in  some  cases.  The  treatment 
in  the  main,  however,  will  consist  in  the  application  of  dressings  and 
bandages,  together  with  such  mechanical  apparatus  as  will  favor  the 
support  of  the  parts.  The  pressure  of  the  bandage  should  be  at  first 
gentle,  but  gradually  increased.  The  bowels  should  be  kept  regular, 
and  the  surface  of  the  body  frequently  bathed. 

The  patient  should  be  advised  not  to  attempt  walking  too  soon  after 
delivery,  and  when  it  is  considered  prudent  to  test  her  strength,  it 
must  be  done  with  great  care.  A  well-padded  leathern  girdle  should 
be  fixed  around  the  hips,  as  tightly  as  the  patient  can  bear,  and  kept 
in  its  place  by  straps  passed  under  the  thighs;  the  upper  part  of  the 
body  should  also  be  supported  on  crutches,  in  order  to  lessen  the  weight 
and  pressure  of  the  trunk  on  the  articulations,  which  must,  at  first,  be 
unable  to  maintain  its  whole  weight. 


STRAITS    AND    CAVITIES    OF    THK    PELVIS. 


29 


CHAPTER  IV. 

STRAITS    AND    CAVITIES   OF   THE   PELVIS THE  PELVIS    AS  A    WHOLE. 

THE  union  of  the  several  bones  already  considered  by  means  of 
their  symphyses  or  articulations,  forms  the  Pelvis,  which  is  of  a  con- 
ical shape,  with  its  base  looking  upward  and  forward,  and  its  apex 
pointing  downward  and  inward.  The  internal  surface  of  the  pelvis  is 
divided  into  the  upper  basin,  false  or  greater  pelvis,  located  above  the 
superior  strait,  and  the  lower  basin,  true  or  lesser  pelvis,  more  com- 
monly termed  the  pelvic  cavity  or  excavation,  and  which  occupies  the 
space  comprised  between,  the  superior  and  inferior  straits — so  called 
because  they  are  rather  more  contracted  than  the  space  between  them. 
The  greater  pelvis  is  bounded  posteriorly  b^y  the  lumbar  vertebra?,  lat- 
erally by  the  ahe  ilii,  and  anteriorly  by  the  abdominal  parietes;  the 
lesser  pelvis  is  marked  posteriorly  by  the  sacrum  and  coccyx,  laterally 
by  the  ischia,  and  anteriorly  by  the  pubes. 

Between  these  two  cavities  is  an  aperture  of  an  elliptical  or  curvili- 
near triangular  form,  somewhat  resembling  the  shape  of  a  playing- 
card  heart,  with  its  base  resting  on  the  sacrum,  and  at  which  location 
a  prominent  ridge  is  observable,  which  has  received  the  names  of  ilio- 
pubic  line,  linea  ilio-pectineal  protuberance  and  brim  of  the  pelvis;  it 
is  formed  by  the  crest  of  the  pubis,  and  the  ridge  which  is  continuous 
along  the  lower  part  of  the  alre  ilii,  and  which,  together  with  the  pro- 
montory of  the  sacrum,  consti- 
tutes the  SUPERIOR  STRAIT.  Ill 
a  well  formed  pelvis  its  circum- 
ference measures  from  fourteen 
to  sixteen  inches.  The  diame- 
ters of  the  superior  strait  are  as 
follows:  1.  The antero-posterior 
or  sacro-publc,  or  conjugate  di- 
ameter (A  A,  Fig.  4),  extending 
from  the  superior- posterior  edge 
'of  the  symphysis  pubis  to  the 
promontory  of  the  sacrum,  DIAMETERS  OF  THE  SUPERIOR  STRAIT. 

measures  from  four  to  four  and  A  A'  Antero-posterior        C  C,  Oblique  Diameters. 

Diameter.  A  C,  Sacro-cotyloid  Space. 

a  half  inches.     2.  The  transverse  B  B,  Transverse  Diameter. 

or  bis-iliac  diameter  (B  B,  Fig.  4),  passing  from  one  ilium  to  the  other, 


FIG.  4. 


30 


KING'S  ECLECTIC  OBSTETRICS. 


FIG.  5. 


and  crossing-  the  antero-posterior  diameter,  at  a  right  angle,  measures 
five  inches.  In  the  recent  subject,  this  diameter  is  lessened  by  the 
psose  and  iliac  muscles,  which  overhang  the  sides  of  the  brim.  3.  The 
oblique  di(tmcters*  (c  c,  Fig.  4),  passing  from  the  ilio  pectineal  emi- 
nence, just  above  the  acetabulum,  to  the  sacro-iliae  symphysis  of  the 
opposite  side,  measure,  each,  from  four  and  a  half  to  five  inches.  The 
one  passing  from  the  right  ilio  pectineal  eminence,  to  the  left  sacro- 
ili:ic  symphysis,  is  called  the  right  oblique  diameter;  and  that  which 
passes  from  the  left  ilio  pectineal  eminence,  to  the  right  sacro-iliac 
symphysis,  is  called  the  left  oblique  diameter.  4.  The  sacro-cotyloid 
space,  or  diameter  (A  C,  Fig.  4),  extending  from  the  center  of  the 
promontory  of  the  sacrum,  to  the  ridge  just  above  the  cotyloid  cavity, 
measures  from  three  and  three-quarters  of  an  inch  to  four  inches. 
The  articulation  of  the  spinal  column  witfi  the  pelvis,  is  such,  that 

the  axis  of  the  superior  strait  is  not 
parallel  with  that  of  the  body,  the  su- 
perior-posterior part  of  the  pubic  sym- 
physis being  about  four  inches  below 
the  level  of  the  sacral  promontory.  If 
a  piece  of  pasteboard  be  accurately 
cut  and  fitted  to  the  pectineal  line,  or 
superior  strait,  it  will  represent  the 
plane  of  that  strait  (c  H,  Fig.  5),  and 
will  be  neither  horizontal  nor  vertical, 
but  will  form,  with  a  horizontal  line, 
an  angle  of  about  54°  to  56°,  varying 
more  or  less  according  to  the  position 
of  the  body.  The  axis  of  the  superior 
strait  will,  therefore,  be  an  imaginary 
line  passing  through  the  center  of  the  plane  at  right  angles  (A  B,  Fig.  5), 
and  will  be  found  to  extend  from  the  neighborhood  of  the  umbilicus, 
downward  and  backward,  to  the  central  portion  of  the  coccyx. 

The  INFERIOR  or  PERINEAL  STRAIT,  also  termed  the  outlet 

*  I  am  aware  that  many  writers  term  the  oblique  diameters,  right  or  left,  accord- 
ing to  the  sacro-iliac  symphysis  from  which  they  commence  their  measurements. 
I  have  always  considered  this  an  incorrect  mode  of  measuring,  one  less  readily 
comprehended  by  the  student,  and  consequently  instead  of  taking  the  posterior 
extremities  of  these  diameters  as  the  origin,  I  commence  at  their  anterior  extrem- 
ities, and  call  the  diameter  right  or  left  oblique,  according  as  its  extremity  is  sit- 
uated anteriorly  and  laterally  to  the  right  or  left  side. 


A  B,  Axis  of  the  Superior  Strait. 
C  H,  Plane  of  the  Superior  Strait. 
C  D,  Horizontal  Line. 
C  D,  Plane  of  the  Inferior  Strait. 
E  G,  Axis  of  the  Inferior  Strait. 


STRAITS   AND    CAVITIES    OF   THE    PELVIS. 


31 


Fia.  6. 


of  the  pelvis,  is  bounded  posteriorly  by  the  apex  of  the  coccyx,  laterally 
by  the  inner  edges  of  the  ischiatic  tuberosities  and  the  sacro-sciatic 
ligaments,  and  anteriorly  by  the  rami  of  the  ischla,  and  the  inner  edges 
of  the  pubic  arch.  Its  circumference  measures  between  thirteen  and 
fourteen  inches.  The  conformation  of  this  strait  is  apparently  very 
irregular,  but  if  a  sheet  of  paper  be  applied  to  it,  and  its  outline 
traced  by  a  pencil,  it  will  be  found  of  an  oval  form,  with  its  large 
extremity  pointed  backward,  and  broken  by  the  projection  of  the 
coccyx.  The  diameters  of  the  inferior  strait  are  as  follows : 

1.  The  antero-posterior  diameter  (A  A,  Fig.  6),  extending  from  the 
lower  edge  of  the  symphysis  pubis 
to  the  apex  of  the  coccyx,  measures 
four  inches,  but  in  some  women  it 
may  be  increased  to  five,  in  con- 
sequence of  the  regression  of  the 
coccyx.  2.  The  transverse,  or  bis- 
ischiatic  diameter  (B  B,  Fig.  6),  ex- 
tending from  one  tuberosity  of  the 
ischium  to  the  other,  measures  four 
inches.  3.  The  oblique  diameters 
(c  C,  Fig.  6),  extending  from  the 
center  of  the  great  sacro-sciatic  lig- 
ament of  one  side,  to  the  point  of 
union  between  the  ascending  ramus 
of  the  ischium  and  descending  ramus 
of  the  pubis,  measure,  each,  from 
four  to  four  and  a-half  inches.  At 
the  period  of  delivery,  this  diameter  may  be  slightly  increased,  owing 
to  the  mobility  of  the  sacro-sciatic  ligaments.  « 

That  which  passes  from  the  right  lateral  anterior  region  to  the  left 
lateral  posterior,  is  called  the  right  oblique  diameter;  and  that  which 
passes  from  the  left  lateral  anterior  region  to  the  right  lateral  posterior, 
is  called  the  left  oblique  diameter. 

An  imaginary  line  extending  from  the  lower  edge  of  the  symphysis 
pubis  to  the  coccygeal  apex,  will  represent  the  direction  of  the  plane 
of  the  inferior  strait  (c  E,  Fig.  5),  and  a  line  passing  through  the  cen- 
ter of  this  plane,  at  right  angles  or  perpendicular  to  it,  will  give  the 
direction  of  the  axis  of  the  inferior  straits  (FG,  Fig.  5),  which  extends 
from  the  center  of  the  strait  to  the  first  sacral  bone,  and  crosses  the 
axis  of  the  superior  strait  near  the  center  of  the  pelvic  cavity,  forming 


DIAMETERS  OP  THE  INFERIOR  STRAITS. 
A  A,  Antero-posterior  diameter. 
B  B,  Transverse  diameter. 
C  C,  Oblique  diameters. 

1.  Base  of  the  Sacrum. 

2.  Pubic  Symphyses  and  Pubic  Crest. 

3.  Anterior-superior  Spinous  Process  of  the 

Ilium. 
4  4.  Obturator  Foramina. 


32 


KING'S    ECLECTIC    OBSTETRICS. 


FIG.  7. 


at  their  point  of  contact  a  very  obtuse  angle ;  it  is  parallel  with  the  axis 
of  the  body.  The  direction  of  tin-  axes  of  the  two  straits,  should  be 
well  understood,  as  they  determine  the  direction  which  the  fetal  head 
takes  in  passing  through  the  pelvis,  and  which  course  should  be  fol- 
lowed whenever  delivery  has  to  be  effected  by  instruments;  the  curved 
direction  of  the  two  axes  through  the  center  of  the  pelvis,  may  be 
considered  as  the  true  axis  of  the  pelvis  (G  K,  F'ty.  7). 

In  consequence  of  the  arrangement  of  the  pelvic  bones,  which 
causes  this  variation  in  the  direction  of  the  axes  of  the  two  straits,  the 
pelvic  contents  are  prevented  from  falling  downward,  which  might 
otherwise,  be  the  result,  either  from  their  own  gravity,  or  from  the 
pressure  of  the  abdominal  viscera  above  them. 

The  PELVIC  CAVITY  or  EXCAVATION,  includes  all  that 
space  occupied  between  the  superior  and  inferior  straits ;  it  is  bounded 
posteriorly  by  the  sacrum,  the  coccyx,  the  sacro-iliac  symphyses,  and 
a  portion  of  the  sacro-sciatic  ligaments;  anteriorly,  by  the  symphysis- 
pubis,  pubic  bones  and  the  internal  obturator  fossa?;  and  laterally,  by 
the  two  inclined  acetabular  planes,  the  sciatic  openings,  and  the  sacro- 

sciaitc  ligaments.  The  canal  of  this 
cavity  possesses  a  curvature  cor- 
responding to  the  curve  of  the  sac- 
rum, and  which  gives  to  it  a  greater 
extent  than  that  of  the  straits.  The 
axis  of  this  canal  represents  the 
route  taken  by  the  fetus  in  its  expul- 
sion through  the  cavity,  and  should 
be  well  understood  by  the  practi- 
tioner, if  he  expects  to  meet  with 
success  in  the  operations  which  may 
be  necessary  to  effect  artificial  de- 
livery. The  axis  of  the  pelvis  is 
not  formed  by  two  straight  lines, 
nor  does  it,  as  supposed  by  Cams 
and  others,  represent  the  arc  of  a 
circle ;  but  it  has  been  well  deter- 
mined by  M.  Cazeaux,  who  ob- 
serves (Fig.  7) : 

"  To  form  an  exact  idea  of  the 
general  disposition  of  the   pelvic 
cavity,  it  seems  best  to  cut  that  canal  by  a  series  of  planes,  passing 


A  B,  Plane  of  the  Superior  Strait. 
I  O,  -Plane  of  the  Inferior  Strait. 
Q',  The  point  where  these  two  planes  would 

meet,  if  prolonged. 
M  N,  The  Horizontal  Line. 
E  F,  The  Axis  of  the  Superior  Strait. 
G  K,  The  Axis  of  the  Pelvic  Cavity. 
P  Q  R  S  T,  Various  points  taken  on  the  Sacrum 

to  show  the  plane  of  the  excavation  at  each 

point. 


STRAITS   AND   CAVITIES    OF  THE   PELVIS.  33 

from  the  point  Q'  (the  point  of  intersection  of  the  planes  of  the  superior 
and  inferior  straits),  to  the  points  r  Q  K  s  T,  of  the  anterior  face  of  the 
sacrum.  Each  one  of  these  planes  will  determine  the  opening  of  the 
pelvic  cavity  at  that  point.  Now,  to  determine  with  precision  the  di- 
rection of  the  general  axis  of  the  excavation,  it  will  be  necessary  to 
erect  a  perpendicular  to  the  geometrical  center  of  each  one  of  these 
sections,  and  to  draw  a  line  («  K)  along  the  extremities  of  the  perpen- 
diculars. This  line  (G  K)  is  curved,  and  is  called  the  general  axis  of 
the  pelvic  cavity.  It  is  easy  to  see  that  this  line  is  nearly  parallel 
with  the  anterior  face  of  the  sacrum,  and  its  extremities  are  lost  in  the 
axes  of  the  superior  and  inferior  straits.  This  curve  represents  exactly 
the  axis  of  the  whole  excavation ;  that  is  to  say,  the  line  which  the 
fetus  traverses  in  passing  through  the  pelvis." 

The  depth  of  the  pelvic  excavation,  posteriorly,  along  the  sacrum 
and  coccyx,  is  from  five  to  six  inches;  laterally,  three  and  a-half 
inches ;  anteriorly,  along  the  os  pubis,  one  and  a-half  to  two  inches. 
Its  diameters  are: 

1.  The  antero-posterior  diameter,  passing  from  the  symphysis  pubis 
to   the   center   of  the   sacrum,  measures   four  and   a-half  inches,  or 
more. 

2.  The  transverse  diameter,  extending  from  the  plane  of  one  ischium, 
to  that  of  the  other,  measures  about  four  and  a-half  inches. 

There  is  considerable  difference  in  form  and  texture,  between  the 
pelvis  of  a  female  and  that  of  a  male.  (Figs.  2  and  3.)  The  female 
pelvis  is  not  so  strong  nor  so  thick  as  that  of  the  male,  and  contains 
less  osseous  matter;  in  the  male,  the  long  diameter  of  the  superior, 
strait,  is  from  before,  backward,  while  in  the  female  it  is  from  side  to 
side;  in  the  male,  the  brim  is  more  triangular;  in  the  female,  more 
oval.  In  the  female  the  ilia  are  more  distant;  the  tuberosities  of  the 
ischia  arc  also  further  apart  from  each  other,  and  from  the  coccyx,  and 
the  space  between  the  pubes  and  coccyx  is  greater  than  in  the  male. 
The  sacrum  of  the  female  is  broader  and  more  curved  than  in  the 
male,  and  the  superior  articulations  are  more  distant  from  each  other, 
occasioning  a  peculiarity  in  her  walking,  apparently  rendering  it 
more  difficult  for  her  to  preserve  the  center  of  gravity.  The  sym- 
physis pubis  is  not  so  long  in  the  female  as  in  the  male,  and  the  ranii 
of  the  pubes  and  ischia  are  smoother  on  their  inner  face,  and  have 
their  anterior  edges  turned  more  outwardly ;  the  obturator  foramen  is 
3 


34  KING'S  KCLKCTIC  OBSTETRICS. 

more   triangular  in  the   female;  and  the    cotyloid  cavities  are  more 
widely  apart. 

The  following  dimensions  of  the  male  and  female  pelvis  are  by 
Meckel : 

IN  THE  MALE.  IN  THK  FEMALE. 

Inches.  Lines.  Indies.   Lines. 
"The  transverse  diameter  of  the  great  pelvis  between 

the  anterior-superior  spinous processes  of  the  ilia. .      78  8          (i 

Distance  between  the  cristse  of  the  ilia 8         3  9          4 

Transverse  diameter  of  the  superior  strait 46  50 

Oblique  diameter  of  the  superior  strait 45  45 

Antero-posterior  diameter  of  the  superior  strait 4         0  4          4 

Transverse  diameter  of  the  cavity 4         0  4         8 

Oblique  diameter  of  the  cavity 5         0  5          4 

Antero-posterior  diameter  of  the  cavity 5         0  4 

Transverse  diameter  of  the  lower  strait  or  outlet 3         0  4          5 

Antero-posterior  diameter  of  the  lower  strait  or  outlet.      33  44 

"  The  latter  may  be  increased  to  5  inches,  from  the  mobility  of  the  coccyx." 

The  above  dimensions  of  the  straits  and  cavity  of  the  female  pel- 
vis are  assumed  as  the  standard,  and  any  considerable  deviation  from 
these  measurements,  may  present  an  obstacle  to  the  progress  of  deliv- 
ery, and  the  pelvis  is  then  said  to  be  vitiated  or  malformed. 

It  may  be  proper  to  make  a  brief  reference  to  some  of  the  vessels 
and  soft  parts  which  cover  the  pelvis,  especially  those  which  occupy 
its  cavity.  In  the  greater  or  false  pelvis,  we  find  anteriorly,  the  mus- 
cles and  the  anterior  parieties  of  the  abdomen,  which  assist  in  com- 
pleting this  basin;  laterally,  the  iliac  fossa3  are  filled  with  the  internal 
iliac  muscles;  and  posteriorly,  are  the  psoas  major  and  minor  muscles, 
which  pass  downward  along  and  on  the  sides  of  the  lumbar  column, 
and  along  the  pelvic  brim,  to  be  inserted  into  the  trochanter  minor. 
These  muscles,  in  connection  with  the  iliac  veins  and  arteries,  are  so 
arranged  as  to  contract  the  size  of  the  transverse  diameter  of  the  su- 
perior strait,  to  even  an  inch  less  than  its  true  length,  thus  apparently 
presenting  its  oblique  diameter  as  the  largest ;  but  these  muscles  are 
capable  of  great  compression,  especially  when  they  are  completely 
relaxed  by  flexing  the  thighs  upon  the  pelvis,  and  hence  in  the  ma- 
jority of  cases,  they  present  but  little  obstacle  to  the  passage  of  the 
fetus. 

The  pelvic  excavation  is  lined  by  fascia,  which  assist  in  diminishing 
its  diameters;  it  is  also  lessened  posteriorly,  by  the  sacral  plexuses  of 
nerves,  the  pyriform  muscles,  the  hypogastric  blood-vessels,  and  the 


DEFORMITIES   OF    THE    PELVIS.  35 

rectum ;  anteriorly,  by  the  bladder,  the  obturator  nerves  and  vessels, 
and  the  internal  obturator  muscles ;  and  in  its  vertical  diameter,  by 
the  floor  of  the  pelvis  or  perineum,  which  is  a  muscular  membranous 
plane  closing  the  pelvis  inferiorly,  acting  in  antagonism  to  the  dia- 
phragm and  abdominal  muscles,  and  on  whose  median  line  are  the 
urinary,  generative,  and  fecal  or  anal  orifices.  Inclosed  within  these 
soft  parts  are  the  vagina  and  uterus.  The  muscles  of  the  perineum 
are:  the  sphincter  ani,  surrounding  the  lower  part  of  the  rectum,  and 
which  arises  from  the  coccyx,  and  is  attached  to  the  center  of  the  peri- 
neum ;  the  sphincter  or  constrictor  vagince,  which  arises  from  the  body 
of  the  clitoris,  and  is  attached  to  the  center  of  the  perineum ;  it  is  about 
fifteen  lines  wide,  and  surrounds  the  anterior  opening  of  the  vagina, 
acting  as  a  sphincter  to  it;  the  erector  clitoridis  arises  from  the  ascending 
ramus  of  the  ischium,  covers  the  inferior  face  of  the  crus  clitoridis, 
and  is  inserted  into  the  upper  part  of  the  crus  and  body  of  the  clitoris; 
it  draws  the  clitoris  downward  and  backward;  and  the  transversalis 
perincei  arises  from  the  fatty  cellular  membrane  which  covers  the  tuber- 
osity  of  the  os  ischium,  and  is  inserted  into  the  perineal  center;  it  keeps 
the  perineum  in  its  proper  place. 


CHAPTER   V. 

DEFORMITIES    OF    THE    PELVIS. 

ANY  remarkable  deviation  from  the  standard  measurements  of  the 
pelvis  produces  a  malformation  or  deformity  of  it;  yet  it  does  not  fol- 
low that  every  slight  variation  should  be  viewed  as  a  deformity,  but  only 
those  instances,  in  which  it  may  so  far  depart  from  its  normal  form  as 
to  render  it  extremely  difficult,  or  even  impossible  to  deliver  the  full- 
grown  fetus  by  the  natural  passage.  A  pelvis,  the  small  diameter  of 
which  measures  three  and  a-half  or  four  inches,  may,  in  case  there  be 
no  unusual  enlargement  of  the  fetal  head,  admit  of  its  safe  passage  at 
full  term  with  but  very  little  difficulty;  below  this  measurement,  say 
from  three  inches  to  three  and  a-half,  the  forceps  will  undoubtedly 
be  demanded ;  if  it  be  still  smaller  than  this,  the  induction  of  prema- 
ture delivery  would  be  prudent  and  justifiable,  and  if  the  fetal  head 
should  be  unable  to  pass,  the  perforator  would  be  required.  In  cases, 


36  KING'S  ECLECTIC  OBSTETRICS. 

however;  where  the  measurement  of  the  small  diameter  does  not  ex- 
ceed one  inch  and  ii-half,  the  perforator  can  not  be  used  with  safety,  ;md 
in  these  instances,  the  Caesarean  section  is  recommended  as  the  only 
chance  for  the  mother's  life. 

The  more  general  causes  of  vitiated  or  malformed  pelvis,  are  rick- 
ets and  mollities  ossium.  Rickets  is  probably  the  most  frequent  cause ; 
this  is  a  disease  common  to  children,  especially  those  of  a  strumous 
diathesis,  and  is  very  seldom  met  with  in  adults.  In  this  affection  the 
bones  become  very  much  softened,  in  consequence  of  the  deficiency  of 
the  calcareous  matters  natural  to  them,  owing  to  their  absorption  or 
non-deposition:  and  in  connection  with  the  disease  there  is  most  usu- 
ally an  arrest  of  development  of  the  bones,  in  which  the  pelvis,  instead 
of  becoming  properly  developed  with  the  growth  of  the  female,  retains 
its  infantile  condition,  and  thus  presents  a  permanent  obstacle  to  de- 
livery. From  these  circumstances  the  bones  curve  unnaturally  in  vari- 
ous directions,  especially  those  upon  which  there  is  much  pressure,  or 
upon  which  is  exerted  a  long-continued  action  of  the  muscles;  and  the 
pelvis  in  particular,  which  sustains  the  weight  of  the  trunk,  becomes 
more  or  less  deformed,  according  to  the  duration  and  severity  of  the 
disease,  and  the  deformity  continues  even  after  the  disease  has  been 
cured.  Most  generally,  this  disease  commences  in  the  bones  of  the 
inferior  extremities,  and  gradually  extends  itself  to  the  pelvis,  the 
spinal  column,  etc. 

TREATMENT.— Children,  affected  with  rachitis,  will  require  both 
hygienic  and  therapeutic  measures  to  overcome  it.  Rachitic  softening 
of  the  pelvic  bones  in  tlie  female  infant,  demands  the  most  careful 
and  pains-taking  treatment — the  deformity  following,  results  in  after 
life  in  the  most  serious  consequences.  The  invigoration  of  fresh  air 
is  one  of  the  first  essentials  in  the  treatment  of  this  disease.  The 
child  should  be  taken  into  the  open  air  every  day,  as  the  weather  will 
permit.  While  indoors,  the  child  should  be  kept  in  a  state  of  rest,  in  a 
reclining  position ;  the  apartment  should  be  well  lighted  and  ventila- 
ted, also  dry,  and  on  damp  days  a  fire  in  an  open  fire-place  would  be 
advantageous.  We  should  next  advise  the  mother  as  to  diet,  and  this 
is  of  the  greatest  importance.  During  the  first  year,  the  child  should  be 
nourished  at  the  breast,  providing  the  mother  is  in  good  condition. 
If  breast  milk  can  not  be  furnished,  cow's  milk  may  be  used,  properly 
diluted.  After  the  age  of  weaning,  the  diet,  recommended,  in  the  Xew 


DEFORMITIES    OF    THE    PELVIS.  37 

York  hospitals,  is  meat  soups,  beef  tea,  peptonized  beef — the  diet 
being  principally  animal.  The  usual  internal  treatment  consists  in 
supplying  lime-salts  to  the  system.  Prof.  J.  Lewis  Smith,  in  his 
Treatise  on  the  Diseases  of  Infancy  and  Childhood,  recommends  the 
following  formula,  which  he  claims  will  be  found  useful  in  most  cases  : 

R  Olei  morrhuae  fgiv 

Aq.  calcis. 
Syr.  calcis  lactophosphatis,  aa  fgij    Misce. 

Of  this,  one  teaspoonful  should  be  given  four  or  five  times  daily  to  an 
infant  of  one  year. 

Lime-water,  codliver  oil,  the  compound  syrup  of  the  phosphates 
are  recommended  by  most  authors  as  valuable  internal  agents  in  the 
treatment  of  this  disease.  The  formula  I  have  quoted  contains  these 
ingredients  in  about  the  proper  proportion.  In  moving  the  patient, 
great  care  should  be  taken  to  prevent  deformities :  the  softened  and 
yielding  bones  may  be  easily  twisted  or  distorted.  Children,  and 
especially  female  children,  who  are  disposed  to  rickets,  should  never 
be  allowed  to  creep  or  walk  at  too  early  an  age,  lest  pelvic  deformity 
occur  as  a  consequence.  Before  exertion  of  lower  extremities  is 
allowed,  as  standing  or  walking,  the  parts  should  be  supported  by  stif- 
fened dressings. 

Mollifies  Osslum,  or  Malacosteon,  is  the  usual  cause  of  those  deform- 
ities which  take  place  during  adult  age,  It  also  consists  in  an  undue 
softening  of  the  bones,  owing  to  the  absence  of  their  salts,  especially 
the  phosphate  of  lime,  and  is  usually  connected  with  a  gouty  or  rheu- 
matic diathesis;  sometimes  it  is  the  result  of  mercurial  treatment. 
This  disease  is  gradual  in  its  progress,  and  the  deformity  resulting 
from  it,  may  occur  in  women  who  have  previously  given  birth  to  sev- 
eral children,  and  who  may  subsequently  become  so  deformed  in  the 
pelvis,  as  to  render  delivery  by  the  natural  passage  absolutely  impos- 
sible. 

The  cause  of  the  deformity,  in  either  rickets  or  mollities  ossium, 
is  essentially  the  same ;  thus,  the  sacrum  being  softened  by  either 
disease,  will,  from  the  superincumbent  pressure,  be  forced  from  its 
natural  position,  occasioning  an  increase  or  decrease  of  the  pelvic 
diameters,  at  the  superior  strait,  inferior  strait,  or  in  the  pelvic  cavity. 
Or  the  oblique  diameter  of  the  pelvis,  or  its  antero-posterior  diameter 
may  be  diminished,  in  consequence  of  the  acetabula  being  driven  in- 


38  KING'S  ECLECTIC  OBSTETRICS. 

ward;  these  alterations  may  exist  singly,  or  may  be  variously  eom- 
bined. 

In  cases  of  Mollities  Ossiutu,  the  TREATMENT  will  be  similar  to 
that  named  for  rickets,  together  with  such  other  measures  as  may  be 
indicated;  however,  the  disease  is  seldom  cured. 

Deformities  of  the  pelvis  may  arise  from  other  causes  than  those  to 
which  I  have  just  referred;  thus,  the  very  erroneous  practice  of  forc- 
ing children  to  walk,  by  means  of  go-carts,  baby -jumpers,  and  the  like, 
may  at  an  early  age  give  rise  to  malformations  which  will  continue 
irremediable  through  life.  When  children  are  allowed  to  walk  vol- 
untarily, gradually  perfecting  this  exercise  as  their  locomotive  organs 
acquire  energy,  strength,  and  development,  deformities  rarely  occur. 
A  child  carried  constantly  on  one  arm,  may  cause  a  malformation,  and 
I  am  acquainted  with  a  lady,  who  has  a  deformed  pelvis,  originating 
from  carrying  her  mother's  children  during  her  girlhood,  constantly 
resting  them  on  the  one  hip.  Carrying  heavy  burdens  in  early  life,  or 
remaining  too  long  in  one  position,  before  the  bones  have  acquired 
the  necessary  firmness,  are  very  apt  to  cause  this  kind  of  malfor- 
mation. 

An  old  unreduced  luxation  of  the  femoral  bones,  caries  of  the 
bones,  exostoses,  the  result  of  syphilitic  or  rheumatic  affections,  im- 
perfectly consolidated  fractures,  and  pelvic  tumors,  may  contribute 
to  deformity  of  the  pelvis,  or  occasion  a  diminution  in  its  capac- 
ity. Sometimes,  it  is  impossible  to  determine  the  origin  of  the  de- 
formity. 

Pelvic  deformity  is  more  common  to  the  females  of  Europe  than 
to  those  of  this  country — which  is  probably  owing  to  the  fact,  that  our 
countrywomen  are  better  nourished,  take  more  healthful  exercise,  and 
are  not  exposed  to  the  many  causes,  common  to  Europe,  which  con- 
tribute to  destroy  health  among  the  working  and  indigent  classes. 
Many  of  the  cases,  which  are  met  with  in  this  country,  are  among 
females,  whose  early  life  was  passed  in  some  portion  of  Europe.  But, 
there  is  no  doubt,  that  as  our  population  increases,  together  with  an 
increase  of  poverty,  factory-working,  etc.,  these  results  will  cease  to 
be  uncommon  among  us. 

The  various  forms,  given  to  the  pelvis  by  the  above  causes,  are  very 
numerous,  and  must  ever  vary,  according  to  the  multitudinous  local 
accidents,  severity  and  duration  of  the  causes,  etc.;  and  to  enter  into  a 
minute  description  of  them,  or  to  arrange  them  into  distinctive  classes, 
is  almost  impossible ;  nor,  indeed,  is  such  an  attempt  absolutely  neces- 


DEFORMITIES    OF    THE    PELVIS.  39 

•feary.  Some  of  the  more  common  deformities  have,  however,  been 
classified  by  authors  as  follows:  1st.  The  abnormally  large  pelvis,  or 
where  there  is  an  excess  of  dimension ;  2d.  The  dwarfish  pelvis,  or 
where  there  is  a  diminution  of  dimension ;  3d.  The  unequally  con- 
tracted pelvis ;  and  4th.  The  obliquely  distorted  pelvis. 

1st.  The  abnormally  large  pelvis  (pelvis •  equaliter  justo  major],  or 
excess  of  the  dimensions  of  the  pelvis.  This  can  not  properly  be 
termed  a  deformity,  yet  its  presence  may  give  rise  to  many  accidents, 
which  it  is  the  duty  of  the  accoucheur  to  prevent  or  relieve.  Females, 
in  the  unimpregnated  state,  in  whom  this  condition  exists,  are  very 
liable  to  various  uterine  displacements,  which  often  prove  extremely 
difficult  to  remedy.  And  during  pregnancy,  from  the  absence  of  due 
support  to  the  uterus  above  the  superior  strait,  this  organ  readily  de- 
scends into  the  pelvic  cavity,  producing  a  sense  of  weight,  with  various 
painful  and  unpleasant  symptoms;  as  painful  or  difficult  micturition, 
constipation,  obstinate  tenesmus,  hemorrhoids,  pains,  cramps,  etc.,  the 
necessary  result  of  compression  of  the  bladder,  rectum,  and  the  blood- 
vessels and  nerves  which  line  the  pelvis,  by  the  enlarged  and  prolapsed 
uterus. 

Again,  during  parturition,  and  especially  if  the  female  should 
exert  herself  by  bearing  down  before  the  os  uteri  be  sufficiently  di- 
lated, the  uterus  may  be  forced  through  the  inferior  strait;  or,  dilata- 
tion being  perfected,  together  with  frequent  and  energetic  uterine  con- 
tractions, the  fetus,  from  the  want  of  proper  resistance,  may  pass 
easily  through  the  pelvic  straits  and  cavity,  and  suddenly  present 
itself  at  the  perineum,  which  has  not  yet  been  sufficiently  distended, 
and  lacerate  it.  Or,  should  the-  perineum  yield  without  laceration, 
precipitate  birth  frequently  follows,  rendering  the  female  exceedingly 
liable  to  hemorrhage,  inversion,  or  other  accidents.  These  inconven- 
iences, however,  may  be  readily  obviated  by  a  careful  practitioner; 
the  recumbent  position  during  the  first  months  of  pregnancy  and  dur- 
ing labor,  will  generally  overcome  them. 

2d.  The  dwarfish  pelvis  (pelvis  equaliter  justo  minor),  or  diminution 
of  the  dimensions  of  the  pelvis.  This  deformity,  although  not  very 
common  to  this  country,  is  occasionally  met  with.  The  pelvis  retains 
the  proper  form  and  dimensions  externally,  yet  its  internal  cavities 
are  very  much  diminished  in  extent,  varying  from  a  quarter  of  an 
inch  to  an  inch,  in  each  of  the  diameters.  This  kind  of  deformity  is 
not  connected  with  rickets  nor  malacosteon ;  nor  can  it  be  attributed 
to  arrest  of  development,  as  the  pelvis  is  usually  well  formed,  and 


40  KING'S  ECLECTIC  OBSTETRICS. 

bears  no  resemblance  to  the  undeveloped  pelvis  of  the  child  ;  its  causes 
are  not  well  understood. 

The  difficulty  in  giving  birth  to 'a  child,  depends  entirely  upon  the 
degree  of  deviation  of  the  pelvic  dimensions  from  the  standard  size, 
and  the  proportions  existing  between  the  diameters  of  the  fetal  head 
and  the  pelvis;  yet  a  pelvis  smaller  than  the  average  size,  may  occa- 
sion no  other  difficulty  than  a  tedious,  disagreeable,  painful,  and  per- 
haps exhausting  labor. 

The  diagnosis  of  this  deformity  is  always  difficult  to  correctly 
determine,  unless  we  have  bad  its  existence  indicated  by  a  previous 
labor,  and  in  cases  where  we  suspect  its  presence  from  the  size  of  the 
patient,  a  certainty  may  be  acquired  by  an  examination.  All  the  di- 
ameters of  the  pelvis  are  equally  contracted  in  the  dwarfish  pelvis, 
hence  it  has  been  termed  "  the  equally  contracted  pelvis,"  and  as  no 
favorable  changes  can  be  effected  in  consequence  of  the  impossibility 
of  bringing  the  long  diameter  of  the  head  to  correspond  with  the  long 
and  uncontracted  diameter  of  the  pelvis,  as  in  the  unequally  contracted 
pelvis,  very  great  obstacles  to  delivery  are  presented,  and  most  labors 
result  fatally  to  both  mother  and  child. 

3d.  The  unequally  contracted  pelvis,  or  partially  deformed  pelvis,  in 
which  there  is  a  great  alteration  c-r  disproportion  between  the  various 
parts,  so  that  during  labor  the  female  is  subject  to  much  suffering,  and 
even  death,  and  the  practitioner  frequently  becomes  embarrassed.  The 
deformity  may  exist  in  the  greater  pelvis,  the  lesser  pelvis,  the  supe- 
rior strait,  the  inferior  strait,  or  in  two  or  more  of  these  united. 

FIG.  8.  The  most  usual  mal- 

formations in  the  greater 
pelvis  are  an  exaggera- 
tion of  the  curvature  of 
the  lumbar  column,  pre- 
senting a  deviation  or 
projection  of  its  anterior 
surface ;  or  the  wings  of 
the  ilia,  or  the  iliac  fossa? 
may  be  turned  too  much 
ELONGATION  OF  THE  ANTERO-POSTERIOR  DIAMETER  outwardly.  These  defor- 
OF  THE  SUPERIOR  STRAIT.  mities  do  not  materially 

affect  either  pregnancy  or  parturition,  although  when  excessive,  they 
undoubtedly  influence  the  presentations  of  the  fetus,  and  sometimes 


DEFORMITIES    OF   THE    PELVIS.  41 

occasion  a  permanent  obliquity  of  the  uterus,  which  may  prevent  the 
natural  expulsion  of  the  child.  (Figs.  8  and  9.) 

The  lesser  pelvis,  or  pelvic  cavity,  may  be  deformed  by  a  deficiency 
or  excess  of  one  or  more  of  its  diameters,  and  which  must,  conse- 
quently, influence,  in  a  greater  or  less  degree,  the  diameters  of  the 
superior  and  inferior  straits — more  frequently  those  of  the  superior 
strait. 

The  antero-posterior  diameter  of  the  superior  strait  may  be  affected 
FIG.  9.  by  the  advancement  of  the  promon- 

tory of  the  sacrum  toward  the  cen- 
ter of  the  strait,  in  which  case  we 
usually  find  an  excessive  curvature 
of  the  sacrum,  which  is  sometimes 
so  great,  that  its  apex  looks  up  to- 
ward the  pubic  arch,  interfering 

T,  "  with  the  antero-posterior  diameter 

DIMINUTION  OP  THE  ANTERO-POSTERIOR  r 

DIAMETER  OF  THE  SUPERIOR  STRAIT,  of  tnc  inferior  strait;  or,  while  the 
AND  ELONGATION  OP  THE  TRANSVERSE  base  of  the  sacrum  diminishes  the 
DIAMETER.  antero-posterior  diameter  of  the  su- 

perior strait,  in  consequence  of  its  abnormal  projection,  its  apex  may 
be  thrown  backward,  and  thus  increase  the  diameter  of  the  inferior 
strait.  Sometimes  the  sacrum  may  be  unchanged,  but  the  pubes  will 
be  found  retreating  toward  the  sacrum,  diminishing  the  antero-poste- 
rior diameter  of  the  brim ;  at  other  times,  both  the  change  in  the  sac- 
rum and  pubes  may  exist  simultaneously. 

The  transverse  diameter  of  the  superior  strait  may  be  diminished 
in  consequence  of  one  side  of  the  pelvis  being  much  narrowed,  or  the 
horizontal  rami  of  the  pubes  may  approximate  toward  each  other,  be- 
coming nearly  parallel,  and  with  this  there  may  likewise  exist  an  ap- 
proach of  the  iliac  bones.  The  forward  projection  of  the  pubes  caused 
by  this  deformity,  increases  the  antero-posterior  diameter  of  the  brim. 
A  diminution  of  the  transverse  diameter  of  the  brim,  is  seldom  accom- 
panied by  an  increase  in  that  of  the  inferior  strait ;  although  it  may  be 
present  where  the  contraction  is  the  result  of  an  upward  and  backward 
dislocation  of  the  femur,  drawing  the  ischiatic  tuberosities  and  pubic 
rami  more  distantly  apart.  The  transverse  diameters  of  both  straits 
may  be  lessened  by  improper  pressure  upon  the  pelvis  at  a  time  when, 
in  consequence  of  disease,  the  bones  are  softened. 

The  oblique  diameter  of  the  superior  strait  may  be  decreased  by 


42  KING'S  ECLECTIC  OBSTETRICS. 

one  side  of  the  pubes  projecting  inwardly,  while  the  other  projects 
outwardly,  or  the  iliac  bones  may  turn  inwardly.  If,  in  the  first 
deformity,  the  long  diameter  of  the  fetal  head  presents  in  the  direction 
of  the  great  oblique  diameter  of  the  brim,  and  the  transverse  occupies 
the  diminished  diameter,  labor  may  terminate  safely  without  artificial 
assistance. 

The  superior  strait  may  not  be  at  all  changed,  while  the  inferior 
strait  is  much  diminished;  thus,  the  antero-posterior  diameter  of  the 
inferior  strait  may  be  lessened  by  the  apex  of  the  sacrum  turning 
within  and  upward  toward  the  pubic  arch;  or  the  coccyx  may  project 
forward  too  much. 

The  transverse  diameter  of  the  inferior  strait  may  be  contracted  in 
consequence  of  the  approach  of  the  ischiatic  tuberosities  toward  each 
other,  as  well  as  of  the  sides  of  the  pubic  arch,  which  will  render  it 
absolutely  impossible  for  the  head  of  the  child  to  pass,  or  even  the 
hand  of  the  accoucheur.  This  deformity  is  the  most  to  be  dreaded; 
the  head  readily  passes  through  the  brim  and  pelvic  cavity,  and  be- 
comes arrested  only  at  the  outlet,  and  the  practitioner,  after  delaying 
for  a  length,  of  time,  in  hope  of  its  expulsion,  is  finally  obliged  to 
employ  the  forceps  or  perforator. 

The  oblique  diameters  of  the  inferior  strait  may  be  changed  by  the 
maldirection  of  the  ischio-pubic  branches. 

These  malcoriformations  of  the  two  straits  may  exist  singly,  and 
sometimes  in  combination,  but  in  opposite  directions;  thus,  if  one 
strait  be  contracted,  the  other  will  be  enlarged.  The  consequences 
which  must  arise  'from  these  various  changes,  will  be  evident  to  the 
student  who  compares  the  diameters  of  the  child's  head  with  those  of 
the  bony  passages  through  which  it  must  pass. 

The  pelvic  cavity  may  be  deformed,  1st,  by  a  turning  backward  of 
the  pubes;  2d,  by  the  abnormal  length  of  the  symphysis  pubis,  which 
retards  delivery  by  preventing  the  head  from  engaging  in  the  arch  of 
the  pubes;  3d,  by  the  too  great  or  small  curvature  of  the  sacrum;  4th, 
by  exostosis,  and  fibro-cartilaginous  morbid  productions.  Various 
other  forms,  than  those  referred  to,  may  be  assumed  by  the  pelvis, 
which,  however,  can  not  be  satisfactorily  classified,  as  they  must  ever 
vary,  according  to  circumstances. 

4th.  The  obliquely  distorted  pelvis.  (F/g.  10.)  This  deformity  is 
usually  dependent  upon  an  arrest  of  development  of  one  or  the 
other  side  of  the  sacrum;  more  generally  the  right  side,  and  which 
occasionally  extends  to,  and  includes  the  ilium.  Nseg6le  was  the  first 
writer  who  seems  to  have  noticed  this  deformity,  and  of  whose  re- 


DEFORMITIES    OF    THE    PELVIS. 


43 


marks  M.  Cazeaux  has  given 
us  the  following  -in  his  work 
on  Midwifery,  translated  edi- 
tion, p.  434: 

"  The  peculiar  characteristics 
of  these  deformed  pelves  are 
as  follows: 

"  1st.  Complete  anchylosis  of 
one  of  the  sacro-iliac  symphyses, 
or  partial  fusion  of  the  sacrum 
and  one  of  the  iliac  bones. 

"  2d.  Arrest  of  development, 
or  defective  development  of 

the    lateral  halt    of  the  Sacrum, 

and  defect  in  the  amplitude  of  ^ 

th 

the  anterior 


FIG 


OBLIQUELY  DISTORTED   PELVIS, 

In  which  the  autero-posterior  diameter  traverses  from 

tory  «*  ^  sacrum  to  th«  left  acetabuim; 

the  left  oblique  diameter  is  also  lessened,  while  tho 

sacral  foramina  of  right  is  normal. 


the  anchylosed  portion.     ' 

"3d.  On  the  same  side,  diminished  length  of  the  ilium,  with  diminu- 
tion in  the  extent  of  the  sciatic  notches  of  this  bone;  that  is  to  say,  the 
distance  from  the  anterior-superior  spinal  process  of  the  jlium,  to  its 
posterior-superior  spinous  process,  as  also  the  length  of  a  line  drawn 
from  a  point  at  the  pelvic  inlet,  corresponding  with  the  sacro-iliac  junc- 
tion, if  it  existed,  along  the  linea  innominata,  and  the  linea  ilio- 
pectinea  to  the  symphysis  pubis,  are  shorter  than  (the  same  distances) 
on  the  other  side.  But  farther  upon  the  anchylosed  bone,  the  part 
corresponding  with  the  articular  surface,  which  is  continuous  without 
interruption,  with  the  sacrum,  is  not  so  high,  and  descends  to  a  shortei 
distance  than  it  does  on  the  opposite  side,  and  than  it  would  do  in  a 
bone  normally  formed;  or  to  express  myself  more  clearly,  if  on  the 
anchylosed  side  we  suppose  the  ilium  and  sacrum  separated,  or  reunited 
only  by  the  interposition  of  a  nbro-cartilaginous  disk,  such  as  exists  in 
the  normal  joint,  the  articular  surface  or  the  reunion  of  the  two  bones 
would  be  found  less  long,  and  would  descend  less  low  than  it  would 
on  the  non-anchylosed  side,  or  upon  the  pelvis  normally  constituted. 

"  4th.  Tho  sacrum  seems  to  be  pushed  toward  the  anchylosed  side 
and  it  is  toward  that  side  that  its  anterior  face  is  more  or  less  turned, 
while  the  symphysis  pubis  is  pressed  toward  the  opposite  side,  a  dispo- 
sition which  prevents  the  symphysis  pubis  from  being  directly  opposite 
the  promontory  of  the  sacrum,  and  gives  it  an  oblique  direction. 

"5th.  On  the  anchylosed  side,  as  much  of  the  internal  surface  of  the 
ilium  as  concurs  to  the  formation  of  the  pelvic  excavation  is  flattened, 


44  KING'S  ECLECTIC  OBSTETRICS; 

and  where  considerable  vitiation  exists,  it  is  almost  entirely  plane,  so 
that  a  line  drawn  from  the  middle  or  even  from  the  posterior  end  of 
the  linea  innominata,  along  the  body  and  the  transverse  branches  of 
the  pubis  to  its  symphysis,  will  be  nearly  straight.  We  have  never 
seen  at  the  lateral  half  of  the  anterior  wall  of  the  pelvis,  of  which  we 
now  speak,  any  inclination  inward,  nor  have  we  ever  especially  noticed 
that  sort  of  fracture  of  the  horizontal  branch  of  the  pubis,  which  is 
observed  in  pelves  deformed  from  the  effects  of  malacosteon  in  adults. 

"6th.  The  other  lateral  half  of  the  pelvis,  that  is  to  say,  the  one  in 
which  there  exists  a  sacro-iliac  synchondrosis,  also  differs  from  the 
normal  condition.  At  first  sight,  in  examining  the  pelvis  under  con- 
sideration, and  especially  where  the  obliquity  is  considerable,  it  is  easy 
to  induce  oneself  to  believe  in  the  normal  conformation  of  the  non- 
anchylosed  half;  but  this  opinion  is  not  correct ;  thus,  let  us  suppose 
two  pelves  equally  contracted,  with  this  difference  only,  that  in  one 
the  left  sacro-iliac  symphysis  is  anchylosed,  in  the  other,  the  anchylosis 
is  on  the  right  side ;  let  a  section  of  each  be  made  so  as  to  pass  through 
the  middle  of  the  sacrum  and  the  symphysis  pubis — if  now  we  under- 
take to  fit  the  right  half  of  the  first  pelvis  to  the  left  half  of  the  second, 
so  that  the.  cut  surfaces  shall  cover  each  other,  we  will  discover  that 
the  pubic  bones  are  separated  by  a  distance  of  from  eight  to  twelve 
lines.  Thus,  the  lateral  half  of  the  pelvis,  which  is  free  from  anchy- 
losis, participates  not  only  in  the  abnormal  situation  and  direction  of 
the  bones,  but  also  in  their  irregular  form,  in  such  a  way  that  in  meas- 
uring this  half,  a  line  drawn  from  the  center  of  .the  promontory  of  the 
sacrum,  along  the  linea  innorainata,  and  pectinea,  to  the  symphysis 
pubis,  would  be  at  its  posterior  half  more  curved,  and  at  its  anterior 
half  less  curved  than  in  a  pelvis  well  formed. 

"7th.  It  folloAvs  from  this,  that  the  pelvis  is  obliquely  contracted, 
that  is  to  say,  in  a  direction  which  would  intersect  a  line  passing  from 
the  anchylosed  joint  to  the  cotyloid  cavity  of  the  opposite  side,  while 
the  extent  of  the  last-mentioned  line  is  not  diminished  but  may  be 
increased  where  the  obliquity  is  very  marked.  In  consequence  of  this, 
the  shape  of  the  superior  strait  (that  is  to  say,  an  imaginary  surface ' 
passing  along  the  linea  innominata  and  the  linea  pectinea  over  the 
sacrum),  and  the  shape  of  the  middle  of  the  excavation  (situated  mid- 
way between  the  superior  and  inferior  straits,  called  the  apertura  pelvis 
media),  would  both  resemble,  properly  speaking,  an  oblique  oval  when 
examined  in  front — the  transverse  or  small  diameter  of  which  would 
be  represented  by  the  contracted  oblique  diameter  of  the  pelvis,  while 
its  great  or  longitudinal  diameter  would  correspond  to  the  other  oblique 


DEFORMITIES    OF    THE    PELVIS.  45 

diameter.  On  this  account  we  may,  as  far  as  the  form  is  concerned, 
term  this  variety  of  pelvic  deformity  the  obliquely  oval  pelvis. 

"That  the  distance  from  the  sacral  promontory  to  the  point  corres- 
ponding to  the  one  or  the  other  cotyloid  cavity  (the  distance  sacro- 
cotyloid),  as  well  as  the  distance  from  the  obtuse  point  of  the  sacrum 
to  the  spine  of  the  ischium  on  either  side,  is  less  on  the  side  where 
the  anchylosis  exists. 

"The  distance  from  the  tuberosity  of  the  ischium  on  the  side  of  the 
anchylosis  to  the  posterior-superior  spinous  process  of  the  ilium  of  the 
opposite  side,  as  well  as  the  distance  between  the  spinous  process  of 
the  last  lumbar  vertebra,  and  the  anterior-superior  spinous  process 
of  the  ilium  on  the  side  of  the  anchylosis,  are  smaller  than  the  same 
measurements  on  the  opposite  side. 

"The  distance  from  the  inferior  edge  of  the  symphysis  pubis  to 
the  posterior  and  superior  spinous  process  of  the  ilium,  when  the 
anchylosis  exists  is  greater  than  that  extending  from  the  same  point 
of  the  symphysis  pubis  to  the  posterior-superior  spinous  process,  of 
the  opposite  side. 

"  The  walls  of  the  pelvic  excavation  converge,  in  a  certain  oblique 
manner,  from  above  downward,  and  the  pubic  arch  is  more  or  less 
contracted,  so  as  to  give  it  a  resemblance  to  the  male  pelvis.  These 
two  conditions,  as  well  as  the  contraction  of  the  sciatic  notch,  the 
diminution  of  the  distance  existing  between  the  spines  of  the  ischia, 
and  the  one-sided  and  defective  development  of  the  sacrum,  bear  a 
direct  proportion  with  the  degree  of  obliquity. 

"Finally,  on  the  flattened  side,  the  cotyloid  cavity  is  placed  more 
directly  in  front  than  is  observable  in  the  normally-formed  pelvis, 
while  on  the  opposite  side,  it  looks  almost  directly  outward,  in  such 
a  way  that  when  examining  the  pelvis  in  front  the  eye  rests  directly 
upon  the  cotyloid  cavity  of  the  flattened  side,  while  the  edge  of  the 
one  on  the  other  side  can  only  be  seen,  or  at  least  very  little  of  its 
cavity. 

"  In  order  to  give  to  those  who  never  have  seen  a  pelvis  of  this 
kind  as  accurate  an  idea  as  possible,  we  will  remark  that  when  first 
seen  they  give  us  the  impression  that  the  deformity  has  been  occasioned 
by  a  pressure  acting  from  above  downward,  and  from  without  to  with- 
in, in  an  oblique  direction  upon  one  of  the  lateral  halves  of  the  an- 
terior pelvic  walls,  and  upon  one  of  the  cotyloid  cavities,  while,  at 
the  same  time,  the  other  half  seems  to  have  been  qpmpressed  on  its 
posterior  portion  from  without  inward. 

" Another  peculiarity  «f  this  variety  of  deformed  pelvis  is,  that  they 


46  KING'S  ECLECTIC  OBSTETRICS. 

differ  from  each  other  only  in  the  degree  of  their  obliquity,  and  at  the 
point  where  the  sacrum  is  soldered  to  the  ilium,  while  in  every  other 
respect  (that  is  to  say,  in  reference  to  the  principal  peculiarities  of  the 
deformity),  they  resemble  each  other  as  much  as  two  eggs.  It  is  on 
this  point  that  a  skillful  person,  not  knowing  this  peculiarity,,  would 
be  disposed  to  take  two  different  specimens  presented  to  his  inspection 
for  the  same,  and  it  would  be  difficult  to  convince  him  of  his  error. 

"  The  condition  of  the  bones  of  the  pelvis  (exclusive  of  the  varia- 
tions already  mentioned),  as  it  regards  their  strength,  their  volume, 
their  texture,  their  color,  etc.,  is  exactly  similar  to  that  of  healthy 
bones,  such  as  are  observed  in  young  persons  exempt  from  all  deform- 
ity. It  is  for  this  reason  that  we  find  on  these  bones  none  of  the 
signs,  either  as  it  regards  form,  etc.,  which  are  met  with,  as  the  con- 
sequence of  rickets  or  malacosteon  of  adults.  If  we  divest  our  mind 
of  the  existing  deformities,  the  pelvis  which  we  have  seen,  would  seem 
to  resemble,  in  general,  the  healthy  pelvis.  The  majority  of  them 
belong  to  the  medium-sized  pelvis,  while  the  others  are  either  under 
or  over  the  average  size.  In  no  case  that  we  have  specially  noticed, 
have  we  discovered  the  least  sign  of  the  existence  of  rickets;  in  none 
have  there  appeared  any  of  the  phenomena,  or  accidents,  or  morbid 
modifications,  wrhich  usually  precede  or  follow  the  English  disease,  or 
the  mollities  ossium  after  puberty.  Nowhere  have  we  been  able  to 
establish  the  injurious  effects  of  external  causes,  such  as  falls,  blows, 
etc.,  and  never  has  there  existed  any  antecedent  pain.  It  has  riot  been 
proved,  in  any  of  the  cases  which  we  have  specially  examined,  that 
there  existed  any  lameness.  In  one  case  only,  we  thought  in  seeing 
the  person  walk  we  observed  a  slight  limp,  but  •  other  connoisseurs 
present  at  the  examination,  did  not  observe  it,  and  the  parents,  and 
all  the  family  of  the  person  in  question,  assured  us  positively,  that 
they  never  remarked  any  lameness. 

"In  the  pelvis  of  this  kind,  with  the  lumbar  vertebrae  attached,  the 
vertebral  column  was  strait  in  the  lumbar  region ;  in  other  cases,  it 
inclined  to  the  side  exempt  from  anchylosis.  In  ail  the  pelves  of  our 
collection,  provided  with  lumbar  vjertebrse,  the  anterior  face  of  the 
bodies  of  the  vertebrae  was  more  or  less  turned  toward  the  anchylosed 
side." 

The  anchylosis  of  the  sacro-iliac  symphysis,  above-named,  as  a 
peculiarity  of  this  deformity,  is  usually  so  perfect,  that  the  articulation 
can  not  be  discovered ;  and  the  two  bones  appear  as  one,  without  any 
perceptible  line  of  demarkation  between  them. 


MALCONFORMATION    OF    THE    PELVIS.  47 

CHAPTER    VI. 

INDICATIONS    OF    MALCONFORMATION    OF    THE    PELVIS. 

UNDOUBTEDLY,  the  greatest  earthly  happiness  consists  in  a  domestic 
life,  where  harmony  and  co-operation  can  be  maintained;  and  there  is 
nothing  so  truly  calculated  to  embitter  it,  and  render  it  a  source  of 
constant  wretchedness  to  husband,  wife,  and  relatives,  as  a  knowledge 
of  the  existence  of  pelvic  malconformation  in  the  wife,  rendering  her 
incapable  of  giving  birth  to  a  full-grown  fetus ;  and  to  determine  such 
conformation  and  capability,  in  the  otherwise  marriageable  female, 
physicians  are  often  consulted.  It  is,  therefore,  highly  desirable  that 
every  practitioner  should  be  thoroughly  acquainted  with  all  the  symp- 
toms and  indications  necessary  to  determine  the  presence  as  well  as  the 
extent  of  a  pelvic  deformity,  for  should  he  decide  incorrectly,  from 
lack  of  proper  information,  and  thus  cause  the  parties  to  engage  in  a 
contract  for  life,  the  responsibility  of  the  death  of  the  female,  accruing 
therefrom,  would  rest  solely  upon  him.  Or,  as  is  sometimes  the  case, 
the  pregnant  woman  may  require  his  knowledge  to  correctly  ascertain 
the  extent  of  malformation,  that  a  course  may  be  pursued  to  preserve 
both  the  parent  and  child,  if  possible — at  all  events  the  mother — also, 
whether  there  would  be  safety  in  allowing  gestation  to  continue  its 
full  term,  or  in  the  induction  of  premature  delivery. 

Various  causes  may  give  rise  to  a  suspicion  of  pelvic  deformity, 
as  the  pre-existence  of  rickets,  fractures,  unusual  shortness  of  the 
inferior  extremities,  or  an  inequality  in  their  length,  as  well  as  an 
inequality  in  the  height  of  the  hips,  etc.;  a  short  female  with  long 
arms,  when  compared  with  the  rest  of  the  body,  projecting  chin,  and 
short,  crooked  legs,  has  also  been  named  among  those  disposed  to 
pelvic  malformation. 

In  the  investigation  of  this  matter,  the  physician  should  make 
himself  as  thoroughly  acquainted  as  possible  with  the  previous  history 
of  the  patient,  even  from  her  infancy ;  the  presence  of  scrofulous 
symptoms,  or  rickets,  or  any  lameness  or  difficulty  in  walking  at 
any  antecedent  period,  any  fall  upon  the  sacrum,  or  carrying  heavy 
weights,  must  be  carefully  inquired  into ;  and  if  there  should  be  found 
any  spinal  curvature,  or  shortening,  or  incurvation  of  the  inferior 
extremities,  the  age  at  which  these  changes  occurred  should  be  noticed; 
though  it  must  be  remembered,  that  pelvic  deformity  is  by  no  means 


48 


KING'S    ECLECTIC    OBSTETRICS. 


a  constant  accompaniment  of  either  of  these  last  named  conditions. 
In  sixty-nine  cases  of  spinal  deformity,  reported  l>y  M.  Bouvier,  there 
were  but  twelve  cases  where  pelvic  deformity  was  present.  Should 
there  be  present  an  inequality  in  the  length  of  the  inferior  extremities. 
it  must  be  ascertained  whether  this  arises  from  dislocations,  or  im- 
properly united  fractures  independent  of  rickets,  or  whether  it  be 
owing  to  rickets,  or  mollities  ossium. 

The  above  indications,  however,  though  they  may  occasion  a  suspi- 
cion of  some  existing  deformity,  are,  of  themselves,  insufficient  to 
give  a  precise  idea  of  its  extent  or  character;  yet  when  they  are  pre- 
sent, they  afford  competent  grounds  for  further  and  more  accurate 
examination.  For  this  purpose  there  are  various  methods  recognized; 
as  the  measurement  of  the  pelvis  by  instruments  designed  therefor, 
termed  callipers,  or  pelvimeters;  or  by  the  employment  of  the  hand. 
The  first  is  termed  instrumental  pelvimetry,  the  latter,  manual  pclvim- 
etry;  and  by  the  term  pelvimetry  is  understood,  a  process  having  for 
its  aim  the  measurement  of  the  various  diameters  and  extent  of  the 
pelvis. 

The  principal  object  for  which  pelvimeters  have  been  used,  is  to 
ascertain  the  capacity  of  the  superior  strait,  which  is  the  fetal  entrance 
to  the  pelvis,  and  more  particularly,  the  extent  of  its  antero-posterior 
-diameter,  though  the  dimensions  of  other  parts  may  likewise  be  deter- 
FI0.  11.  mined  by  some  of  them.     The  pelvim- 

eters most  usually  employed,  are  Cou- 
touly's,  Stark's,  Baudelocque's,  Mad. 
Boivin's,  Simeon's  and  Stein's;  some 
of  which  are  for  external  pelvic  measure- 
ment, and  the  others  for  internal. 

Baudelocque's  pelvi meter  is  for  ex- 
ternal examination,  and  is  most  com- 
monly preferred  to  any  others  yet  in- 
vented for  that  purpose.  It  (F'njiire 
11)  consists  of  two  movable  metallic 
branches  or  arms,  curved  externally 
in  a  semicircular  form,  and  of  sufficient 
concavity  to  embrace  the  hips,  or  antero- 
posterior  diameter  of  the  pelvis.  One 
extremity  of  these  arms  is  straigl.' 
for  the  distance  of  about  five  inches,  and,  at  its  superior  portion,  is 
attached  to  its  fellow  by  a  hinge,  while  the  other,  or  free  extremity 
terminates  in  a  knob,  or  button.  At  the  inferior  portion  of  the 


PEL.VIMETER. 


MALOOXFORMATION    OF    THE    PELVIS.  49 

straightened  arms  of  the  compass,  commences  its  curvature,  and  at 
this  point  a  graduated  scale  is  attached,  which  moves  in  a  groove,  and 
indicates  the  degree  of  separation  of  the  free  extremities.  The  instru- 
ment should  always  be  applied  to  the  naked  body.  In  an  examina- 
tion, one  of  the  knobs  must  be  placed  on  the  first  spinous  process 
of  the  sacrum,  which  will  be  found  a  short  distance  below  the  hollow 
of  the  loins,  and  the  other  must  be  placed  on  the  symphysis  pubis, 
or  in  the  separation  of  the  labia  majora  at  the  most  elevated  point 
of  the  anterior  commissure  of  the  vulva;  and  in  effecting  this,  the 
skin  must  be  carefully  drawn  upward,  so  as  to  reach,  as  nearly  as 
possible,  the  upper  part  of  the  symphysis  pubis,  or  else  an  error  of 
several  lines  may  be  made.  This  position  of  the  instrument  indicates 
the  distance  from  the  posterior  edge  of  the  spinous  process  of  the 
sacrum  to  the  anterior  surface  of  the  symphysis  pubis,  which,  in  a 
well-formed  pelvis,  will  be  seven  inches.  But,  in  order  to  determine 
the  precise  extent  of  the  antero-posterior  diameter  of  the  superior 
strait,  the  thickness  of  the  sacrum,  two  and  a  half  inches,  as  well  as 
that  of  the  symphysis  pubis,  half  an  inch,  must  be  subtracted  from 
the  external  measurement,  seven  inches,  and  which  will  give  four 
inches  as  the  length  of  the  diameter  sought. 

From  the  fact,  however,  that  the  knob  of  the  posterior  extremity 
can  not  always  be  correctly  placed  upon  the  first  spinous  process  of 
the  sacrum,  and  that  there  is  more  or  less  variation  in  the  thickness  of 
the  soft  parts  over  which  the  instrument  is  to  be  applied,  as  well  as  of 
the  bones,  and  especially  in  the  latter  cases,  where  there  has  been  an 
arrest  of  development,  the  measurement  of  the  antero-posterior  diam- 
eter of  the  superior  strait,  obtained  by  Baudelocque's  pelvimeter,  can  not 
be  depended  upon  as  being  definitely  certain;  neither  can  the  instru- 
ment be  rendered  useful  in  the  detection  of  other  varieties  of  mal- 
formation, whether  dependent  on  exostosis,  projection  of  the  sacral 
promontory,  or  other  causes.  And  although  its  use  is  recommended  in 
cases  where  minute  accuracy  is  not  required,  and  in  those  unmarried 
females  in  relation  to  whose  pelvic  dimensions  the  physician  is  con- 
sulted, in  each  of  which  instances  its  employment  may  aid  us  in  our 
diagnosis;  yet  a  reliance  solely  upon  its  indications  is,  under  all  cir- 
cumstances, exceedingly  imprudent  and  hazardous. 

These  objections  to  Baudelocque's  pelvimeter,  occasioned  the  inven- 
tion of  Coutoufy's  pelvimeter,  which,  unlike  the  former,  is  designed  for 
the  internal  measurement  of  the  pelvis.  It  is  composed  of  two  straight 
steel  arms,  parallel  with  each  other,  and  which  slide  with  equal  facility, 
the  one  upon  the  other;  these  terminate  in  two  raised  extremities,  and 
4 


50 


KING'S    ECLECTIC   OBSTETRICS. 


FIG.  12. 


when  introduced  into  the  vagina,  one  of  the  extremities  is  applied 
against  the  symphysis  pubis,  and  the  other  against  the  promontory  of 
the  sacrum;  the  application  of  which,  however,  is  exceedingly  difficult 
to  effect  with  accuracy.  To  the  horizontal  branch  is  attached  a  scale, 
which  indicates  the  exact  amount  of  separation  of  the  two  extremities. 
The  introduction  of  this  instrument  is  difficult,  always  attended  with 
more  or  less  pain,  and  rather  disgusting  to  female  delicacy  ;  all  of  which 
render  its  employment  very  objectionable. 

The  pelvimeter  of  Coutouly  has  undergone  several  modifications, 
though  the  same  objections  still  remain.  The  improvement  of  this 
instrument,  by  Prof.  M.  Van  Huevel,  at  Brussels,  is  considered 
superior  to  any  other.  The  following  description  of  it  is  given 
by  Tucker: 

"  This  instrument  is  composed  of  two 
metallic  rods,  A  A  and  B  B  (Fig.  12),  united 
by  means  of  a  joint,  so  arranged  as  to  allow 
the  extension  of  the  rods  at  pleasure,  at  the 
same  time  that  this  joint  may  be  tightened 
by  means  of  a  nut-screw.  The  rod  A  A,  in- 
tended to  be  introduced  into  the  vagina,  is 
curved  anteriorly,  and  flattened  at  its  ex- 
tremity in  the  form  of  a  spatula;  the  other 
rod,  B  B,  is  not  so  long,  and  is  traversed  at 
one  extremity  by  a  rod,  c,  movable  backward 
or  forward,  by  means  of  a  screw.  In  apply- 
ing this  instrument,  the  female  is  placed  upon 
her  back,  with  the  legs  and  thighs  well 

„          ,  flexed,  and  separated  as  widely  as  possible. 

VAN  HUEVEL'S  PELVIMETER.  -,• 

The  point  on  the  skin  corresponding  to  the 

upper  edge  of  the  symphysis  pubis,  should  be  marked  with  a  dot 
of  ink;  at  the  same  time,  a  similar  mark  may  be  made  to  desig- 
nate the  position  of  the  ilio-pectineal  eminence,  for  the  purpose  of 
measuring  the  oblique,  as  well  as  the  antero-posterior  diameter  of 
the  superior  strait.  This  being  done,  one  or  two  fingers  should  be 
introduced  into  the  vagina,  and  placed  against  the  sacral  promon- 
tory ;  when  this  has  been  found,  the  internal  rod,  A  A,  is  to  be 
inserted  into  the  vagina,  and  carried  along  the  fingers  to  the  pro- 
montory of  the  sacrum,  against  which  the  broad  extremity  of  the 
rod  is  to  be  placed.  In  this  position  it  may  be  firmly  held  by  hook- 
ing the  thumb  of  the  hand  introduced  into  the  vagina,  over  the 
hook  attached -to  the  rod  A  A.  When  this  rod  has  been  accurately 


M A LCOX FORMATION    OF    THE    PELVIS. 


51 


placed,  the  button  extremity  of  the  rod  C,  FIG.  13. 

.should  be  fixed  upon  the  dot  of  ink,  indi- 
cating the  superior  edge  of  the  symphysis 
pubis.  When  the  point  of  union  between 
the  two  rods  has  been  made  firm,  by  tightly 
screwing  the  nut,  the  instrument  may  be 
withdrawn,  and  the  distance  from  the  ex- 
tremity of  the  rod  c  to  that  of  A  A,  may  be 
ascertained.  But,  in  order  to  obtain  the 
length  of  the  sacro-pubic  diameter,  we  must 
subtract  the  thickness  of  the  pubis,  and  to 
do  this,  it  must  be  measured  by  reintroduc- 
ing  the  instrument,  as  is  seen  in  Fig.  13. 
The  distance  first  ascertained,  minus  the 
thickness  of  the  pubis,  will  give  us  the  exact 
length  of  the  antero-posterior  diameter  of 
the  pelvic  brim.  VAN  HUEVEL'S  PELVIMETER. 

"The  length  of  the  oblique  diameter  may  be  ascertained  in  a  similar 
manner.  In  this  case,  the  extremity  of  the  rod  A  A,  must  be  placed 
against  the  sacro-iliac  junction,  while  that  of  the  rod  C  will  rest  on  a 
point  a  little  external  to  the  iliac  artery.  If  the  sacro-iliac  junction 
can  not  be  reached,  we  may  measure,  instead  of  the  obliqu'e  diameter, 
the  distance  sacro-cotyloid,  which  will  give  us  every  measurement  of 
importance,  since,  where  the  oblique  diameter  is  contracted,  it  is  due 
(except  in  some  cases  of  exostosis),  not  to  compression  inward  of  the  sac- 
ro-iliac joint,  but  to  that  of  the  sacral  promontory  or  the  cotyloid  cavity. 

"  This  instrument  may  be  employed  also  in  measuring  the  pelvis 
externally,  but  its  application  in  this  case  is  too  simple  to  require 
farther  explanation." 

The  other  pelvimeters,  by  Stein,  Simeon,  and  Mad.  Boivin,  are 
somewhat  similar  in  construction  to  those  just  named,  and  are  liable  to 
the  same  objections.  The  pelvimeter  of  Stark,  is  rather  simple  in  its 
formation,  but  is  decidedly  objectionable,  on  account  of  its  application 
requiring  the  introduction  of  the  whole  hand  within  the  vagina,  which 
w\)uld  be  exceedingly  improper  in  an  unmarried  female;  beside  which, 
in  a  small  or  deformed  pelvis,  much  pain  and  difficulty  must  necessarily 
attend  its  use.  Prof.  Lazarewitch,  of  Charkoff,  Russia,  has  devised  a 
pelvimeter  which  may  be  used  for  internal  or  external  measurements, 
or  for  these  two  combined ;  it  is  in  many  respects  superior  to  any  that 
have  yet  been  presented  to  the  profession,  but  has  not  been  generally 
received. 


52  KING'S  KCLKCTIC  OKSTKTUICS. 

All  artificial  pelviineters  are  liable  to  more  or  less  inaccuracy,  and 
in  some  instances  are  of  no  use  at  all;  still  we  should  not  omit  their 
employment  in  those  cases  which  come  before  us  for  examination,  as 
they  will  usually  afford  some  aid  toward  forming  a  correct  diagnosis. 
The  hand,  and,  under  certain  circumstances,  the  index  finger  of  the 
accoucheur,  when  skillfully  introduced  into  the  vagina,  is  undoubtedly 
the  most  certain  and  accurate  pelvimeter  we  have,  and  can  be  employed 
with  all  females,  whether  married  or  not.  I  am  aware  that  writers 
generally  oppose  the  use  of  the  finger  in  the  examination  of  the  un- 
married, and  would  impress  it  upon  all  practitioners  as  a  correct  rule 
by  which  to  be  governed,  more  especially  in  this  country,  where  pelvic 
deformities  are  rarely. to  be  met  with;  but  when  the  female  has  arrived 
at  the  marriageable  period,  and  is  about  to  enter  into  wedlock,  yet 
doubts  are  entertained  as  to  the  perfect  formation  of  the  pelvis,  and 
the  other  indications  lead  us  strongly  to  suspect  some  defection,  we 
should  not  hesitate  a  moment  in  performing  a  manual  exploration,  con- 
sidering the  future  health,  happiness,  and  life  of  the  individual  of  too 
much  importance  to  herself,  her  friends,  and  society,  to  be  trifled  away 
by  an  unwise  regard  to  customs  or  opinions,  which  are  only  strictly 
applicable  to  the  healthy,  and  those  of  perfect  conformation. 

In  the  manual  examination,  it  is  preferable  to  have  the  female 
standing  erect,  with  her  shoulders  against  the  wall;  the  index  finger, 
having  been  previously  oiled,  should  then  be  carefully  introduced  into 
the  vagina,  with  the  end  of  the  finger  pointing  upward  and  backward 
in  the  direction  of  the  promontory  of  the  sacrum.  If,  when  the  radial 
portion  of  the  finger  has  reached  the  lower  edge  of  the  symphysis 
pubis,  the  sacral  promontory  can  not  be  felt,  we  may  safely  determine 
that  this  diameter  of  the  superior  strait,  the  antero-posterior,  is  not 
deformed;  but  if  the  sacral  promontory  can  be  felt,  a  mark  should  be 
made  upon  the  finger,  at  its  point  of  contact  with  the  symphysis  pubis, 
(or  the  index  finger  of  the  other  hand  may  be  placed  upon  this  part 
and  held  there),  and  then  withdrawing  it,  the  distance  between  the 
mark  and  extremity  of  the  finger  will  give  us  the  exact  measurement 
of  this  diameter,  if  we  deduct  from  it  six  lines,  for  the  thickness  of 
the  symphysis  pubis,  and  two  or  three  lines  for  the  obliquity  of  tlie 
measurement. 

But  this  is  only  useful  where  the  pelvis  is  much  distorted,  or  where 
the  antero-posterior  diameter  of  the  brim  is  less  than  three  inches. 
Other  methods  have  been  advised  where  greater  accuracy  is  required, 
such  as  the  introduction  of  the  whole  left  hand  within  the  vagina,  to 
such  a  distance  that  the  external  edge  of  the  little  finger  may  be  placed 


MALCONFORMATION    OF    THE    PELVIS. 


against  the  inner  surface  of  the  symphysis  pubis,  and  the  first  finger 
against  the  promontory  of  the  sacrum.     As  the  FIG.  14. 

hand  must  be  opened,  after  having  entered  with- 
in the  vagina,  the  practitioner  can  ascertain  both 
the  antero-posterior  and  transverse  diameters, 
by  knowing  whether  the  whole  width  of  the 
digital  extremities  of  the  hand  can  be  introduced 
into  the  space  under  investigation — whether  he 
must  spread  his  fingers  to  touch  the  extreme 
limits  of  the  diameters — or,  whether  he  can 
only  introduce  two  or  three  fingers.  In  the 
first  instance,  the  diameters  will  be  equal  to 
the  width  of  the  digital  extremities  of  the 
hand;  in  the  second,  they  will  be  more  than 
three  inches,  and  perhaps  four;  and  in  the 
latter,  the  measurement  will  be  from  one  and  MANUAL  PELVIMETRY. 
a  half  to  three  inches,  according  to  the  measure  of  the  fingers  intro- 
duced. (Fig.  14.) 

The  distances  between  the  ischiatic  tuberosities  can  be  ascertained  by 
moving  the  finger  from  side  to  side,  or  by  means  of  a  pair  of  compasses 
applied  externally.  The  finger  can  likewise  measure  the  antero-pos- 
terior diameter  of  the  inferior  strait,  by  applying  its  radial  portion  to 
the  symphysis  pubis,  with  the  extremity  pointing  toward  the  apex  of 
the  coccyx.  The  transverse  and  oblique  diameters  of  the  superior 
strait  may  also  be  ascertained,  sufficiently  accurate  for  all  practical 
purposes,  by  carefully  examining  the  circumference  of  the  brim  with 
the  finger,  in  cases  where  this  is  practicable. 
The  length  of  the  symphysis  pubis,  the  curve 
of  the  sacrum,  the  projection  of  the  spine  of 
the  ischium,  the  shape  of  the  straits,  the  con- 
dition of  the  lateral  parietes  of  the  cavity,  and 
the  presence  of  any  tumor  within  the  pelvis, 
can  always  be  decided  by  the  finger  much 
better  than  by  any  instrument.  And  in  cases 
where  the  fetal  head  does  not  advance  during 
labor,  the  finger  can  readily  determine  the  space 
existing  between  the  circumference  of  the  head 
and  that  of  the  pelvis,  and  thus  instruct  us 
whether  the  pelvis  be  sufficiently  proportioned 
or  not. 

In  cases  where  the  child's  head  is  somewhat     MANUAL  PELVIMETRY. 


FIG.  15. 


54  KING'S  ECLECTIC  OBSTETRICS. 

protruded  into  the  pelvis,  even  when  the  brim  is  contracted,  and  the 
hand  can  not  in  consequence  be  carried  up  to  make  an  accurate  ex- 
amination, Ramsbotham  recommends  two  fingers  of  the  left  hand 
to  be  introduced  within  the  vagina,  the  extremity  of  the  first  finger 
being  placed  exactly  behind  and  against  the  symphysis  pubis,  and  the 
tip  of  the  second  against  the  sacral  promontory.  If  the  examiner  will 
then  carefully  withdraw  the  fingers,  keeping  them  steady,  the  distance 
between  their  extremities  may  be  measured  on  a  scale  of  inches,  or 
otherwise,  and  thus  give  the  exact  dimensions  of  the  antero-posterior 
diameter.  (Fig.  15.) 


CHAPTER  VII. 

THE    FETUS,  ITS    DIVISIONS    AND    DIMENSIONS. 

IN  order  to  understand  the  mechanism  of  labor,  beside  having  a 
knowledge  of  the  pelvis  and  its  divisions,  it  is  likewise  necessary  to 
become  well  acquainted  with  the  dimensions  of  the  various  parts  of  the 
fetus,  especially  those  which,  from  increase  of  size,  may  render  it  diffi- 
cult or  even  impossible  for  labor  to  progress.  Accoucheurs  generally 
divide  the  fetus  into  three  distinct  parts,  namely :  the  head,  the  trunk, 
the  extremities;  some,  however,  in  consequence  of  the  peculiar  manner 
in  which  it  is  curved  upon  itself  when  within  the  uterine  cavity,  object 
to  this  division,  and  prefer  another,  comprising,  1,  the  cephalic  ex- 
tremity, or  head;  2,  the  pelvic  extremity,  including  the  pelvis  and  the 
inferior  extremities;  and  3,  the  torso,  or  trunk,  having  reference  to 
the  parts  between  the  head  and  upper  pelvis.  But  the  first  arrange- 
ment is  sufficient  for  all  practical  purposes. 

The  head  is  of  an  oval  shape,  and  is  the  largest  and  least  reducible 
part  of  the  fetus,  and  a  familiarity  with  its  obstetric  divisions  and 
dimensions  is  highly  necessary  for  the  successful  accoucheur.  The 
bones  of  the  fetal  cranium  are  the  same  in  number  as  in  the  adult 
head,  but  they  are  soft,  and  are  not  united  by  firm  sutures  as  in  the 
adult;  their  imperfect  ossification  gives  rise  to  membranous  spaces  be- 
tween them  of  greater  or  lesser  extent,  called  commissures  or  sutures, 
from  the  Latin  word  suo,  to  sew,  and  which  are  often  of  much  benefit 
to  the  safety  of  the  child  during  its  passage  through  the  pelvic  canal, 
inasmuch  as  in  every  delivery  they  admit  a  certain  degree  of  com- 


THE    FETUS — ITS    DIVISIONS,  ETC.  55 

pression  or  reduction  of  the  head,  and  even  a  riding  of  the  bones  over 
each  other.  They  also  serve  as  indications  by  means  of  which  the 
position  of  the  head  in  the  pelvis  may  be  correctly  ascertained.  There 
are  several  of  these  sutures,  but  those  which  are  the  most  important 
are  three  in  number — the  others  are  of  no  practical  utility  in  an  ob- 
stetrical point  of  view. 

1st.  The  sagittal  or  median  suture  or  commissure,  is  situated  between 
the  two  frontal  and  the  two  parietal  bones,  and  extends  from  the  root 
of  the  nose  to  the  superior  angle  of  the  occipital  bone,  dividing  the 
anterior  and  superior  portion  of  the  cranium  into  two  equal  parts ; 
anteriorly,  it  is  crossed  at  right  angles  by  the  coronal  suture,  and  ter- 
minates posteriorly  at  the  lambdoidal  suture.  Occasionally,  but  very 
rarely,  instances  are  found  where  this  suture  extends  throughout  the 
occipital  bone,  dividing  it  into  two  parts. 

2d.  The  coronal  suture,  sometimes  called  the  transverse,  anterior,  or 
fronto-parietal,  crosses  the  sagittal  suture  at  right  angles,  separating 
the  frontal  from  the  parietal  bones,  and  extends  from  the  extremity 
of  the  greater  wing  of  the  sphenoid  bone  of  one  side,  to  that  of  the 
opposite  side. 

3d.  The  lambdoidal,  or  occipito-parietal  suture,  separates  the  upper 
edge  of  the  occipital  bone  from  the  posterior  edges  of  the  parietal 
bones ;  in  shape  it  resembles  the  Greek  capital,  lambda. 

At  the  points  of  intersection  and  junction  of  these  commissures  are 
membranous  spaces  or  openings,  occasioned  by  the  incompleteness  of 
the  ossification  of  the  angles  of  the  bones.  There  are  six  of  these 
spaces  in  the  fetal  head,  of  which  a  knowledge  of  but  two  is  all  that 
is  required  for  practical  purposes;  they  are  technically  termed  fon- 
tanelles  from/ons,  a  fountain;  they  have  also  been  called  bregmas,  from 
a  Greek  word  signifying  "to  sprinkle,"  each  name  originating  from 
an  ancient  idea  that  a  moisture  passed  from  the  brain  through  these 
membranous  spaces. 

The  anterior  fontanelle,  also  called  the  bregmatic,  or  frontal,  is  the 
opening  situated  at  the  intersection  of  the  coronal  and  sagittal  com- 
missures; it  is  of  a  quadrangular  or  diamond-shape,  and  may  be  dis- 
tinguished by  the  four  bony  angles,  the  edges  of  which  are  soft  and 
smooth,  being  almost  always  tipped  with  cartilage.  The  opening  is 
of  considerable  size,  which,  however,  varies  in  different  heads,  and 
the  finger  can  readily  detect  it  by  its  soft,  smooth,  and  yielding 
character. 

The  posterior  or  occipital  fontanelle,  is  situated  at  the  center  or  angle 
of  the  lambdoidal  commissures  at  its  point  of  junction  with  the  pos- 


56  KING'S  KCLKCTIC  OKSTKTKICS. 

terior  extremity  of  the  sagittal  commissure. •  In  the  immature  fetus  it 
may  he  felt  distinctly,  but  in  the  full-developed  infant  it  consists  of 
merely  a  kind  of  triangle  formed  by  the  meeting  of  the  two  commis- 
sures, and  is  frequently  wanting.  This  fontanelle  may  be  distinguished 
by  its  triangular  shape ;  its  narrowness,  being  much  smaller  than  the 
anterior  fontanelle;  having  but  three  bony  angles;  and  in  consequence 
of  the  more  complete  ossification  of  the  edges  of  the  bones,  they  im- 
part to  the  finger,  on  pressure,  a  hard  serrated  sensation,  which  is 
never  possessed  by  the  edges  of  the  anterior  fontanelle,  and  which, 
therefore,  will  enable  the  practitioner  to  distinguish  the  one  fontanelle 
from  the  other.  In  many  instances  the  posterior  fontanelle  is  so  small 
that  it  can  only  be  distinguished  by  the  three  commissure  lines  that 
radiate  from  a  common  center. 

It  has  been  previously  remarked,  that  occasionally  the  sagittal  com- 
missure continues  throughout  the  occipital  bone,  dividing  it  into  two 
parts,  and  in  instances  where  this  occurs,  four  bony  angles  will  be  per- 
ceived by  the  finger.  The  practitioner,  however,  can  not  err  in  this, 
if  he  will  recollect  that  the  posterior  fontanelle  is  always  smaller, 
and  its  edges  rougher  and  harder  than  the  anterior,  and  that 
on  the  slightest  compression  of  the  head,  the  occipital  bone  al- 
ways glides  under  the  ossa  parietalia.  The  anterior  fontanelle  is 
invariably  larger  than  the  posterior,  no  matter  how  well  marked  this 
last  may  be. 

A  thorough  knowledge  of  the  sutures  and  fontanelles  is  absolutely 
required  in  the  practice  of  midwifery — for  it  is  from  them  that  the 
position  of  the  head  within  the  pelvis  is  ascertained  with  certainty; 
and  in  cases  where  interference  is  demanded,  from  a  too  early  de- 
parture of  the  head  from  its  proper  or  flexed  position,  or  from  some 
other  cause,  the  educated  accoucheur  can  at  once  render  the  necessary 
assistance  to  bring  the  labor  to  a  safe  and  prosperous  termination.  But 
if  he  have  neglected  to  inform  himself  on  these  points,  his  patient  may 
be  subjected  to  much  unnecessary  suffering,  and,  perhaps,  from  lack 
of  timely  aid,  the  death  of  both  mother  and  child  may  ultimately 
ensue.  Hence,  a  peTfect  acquaintance  with  these  peculiar  marks  can 
not  be  too  strongly  impressed  on  the  mind  of  the  student.  It  is  from 
these  alone,  that  the  situation  of  the  head  when  in  the  pelvis  can  be  cor- 
rectly ascertained,  and  never  by  an  ear,  nose,  or  other  part  of  the  head. 

There  are  four  principal  DIAMETERS  belonging  to  the  fetal 
head,  viz.: 

1.  The  large,  oblique,  or  occipito-mental  diameter  (A  B,  Fig.   16), 


THE    FETUS — ITS    DIVISIONS,    ETC.  57 

•extending    from    the    vertex    or   posterior  FIG.  15. 

fontanelle   to   the   symphysis  of  the   chin ; 

its  measurement  is  from  five  to  five  and 

a  half  inches.     It  is  important  to  recollect 

this  diameter,  for  if  it  enters  the  cavity  with 

either  .extremity  descending,  it  can  not  be 

reversed,   from   want  of   space,   but    must 

either  be  allowed  to  escape  as  it  presents, 

or  be  returned  above  the  superior  strait  to 

effect  a   change.      This  diameter   may   be 

*  i       •  i  .IT  •  /  .0,  DIAMETERS  OF  THE  FETAL 

saielv    elongated    by    compression    ot    the  TJ 

~  *  HEAD. 

cranium  with  the  forceps  or  otherwise,  to  A  B  occipito-mcntai. 
the  extent  of  six  or,  ten  lines,  so  that  its  D  E-  Occipito-fnmtai. 

,  C  H.  Cervico-bregmatic. 

whole  measurement  may  be  six  or  seven  T  G.  Tracheio-bregmatic,  or  vertical 

inches  A  ^'  Front°-mental,  or  facial. 

2.  The    longitudinal,   horizontal,   antero-posterior  or   occipito-frontal 
diameter  (D  E,  Fig.  16),  extends  from  the  center  of  the  forehead  to 
the  occipital  protuberance;  its  measurement  is  from  four  to  four  and 
three-quarter  inches. 

3.  The  perpendicular,  vertical,   occipito-bregmatio   or   trachelo-breg- 
matic  diameter  (Gi,Fig.  16),  extends  perpendicularly  from  the  most 
elevated  point  of  the  vertex,  or  top  of  the  head  to  the  anterior  portion 
of  the  great  occipital  foramen ;  its  measurement  is  from  three  and  a 
half  to  three  and  three-quarter  inches. 

4.  The  small,  transverse  or  bi-parietal  diameter  (A  B,  Fig.  17),  ex- 
tends from  the  center  of  one  parietal  protuberance  to  that  of  the  other; 
its  measurement  is  from  three  and  a  half  to  nearly  four  inches.     This 
diameter  may,  by  compression  of  the  cranium  with  the  forceps  or 
otherwise,  be  diminished  one-third  or  even  three-fourths  of  an  inch, 
without  any  injury  to  the  child. 

In  addition  to  these  measurements  of  the  fetal  head,  with  which 
the  student  must  become  familiar,  authors  have  given  several  others, 
a  knowledge  of  which,  however,  is  not  necessarily  important  in  prac- 
tice ;  they  are : 

1.  The  cervico-bregmatic  diameter   (c  H,  Fig.   16),  whioh   extends 
from  the  back  part  of  the  neck  to  the  center  of  the  anterior  fonta- 
nelle; it  measures  from  three  and  a  half  to  three  and  three-quarter  € 
inches. 

2.  The  fronto-mental  or  facial  diameter  (A  D,  Fig.  16),  extends  from 
the  symphysis  of  the  chin,  to  the  center  of  the  forehead ;  it  measures 
from  three  to  four  inches. 


58 


KING'S    KCLECTIC    OBSTETRICS. 


3.  The  post  trachelo-frontal  diameter,  which  extends  from  a  point 
midway  between  the  occipital  protuberance  and  the  occipital  foramen, 
to  the  center  of  the  frontal  bone ;  it  measures  from  four  to  four  and 
three-quarter  inches. 

4.  The  prce-trachelo  occipital  diameter,  extends  from  the  hyoid  bone 
to  the  posterior  fontanelle ;  it  measures  from  three  and  a  half  to  four 
inches. 

5.  The  bi-temporal  diameter  (c  D,  Fig.  17),  extends  from  the  root 
of  the  zygomatic  process  on  one  side  to  the  same  point  opposite;  it 
measures  from  two  and  three-quarters  to  three  inches. 

6.  The  sub-occipito  bregmatie  diameter,  extends  from  a  point  midway 
between  the  foramen  magnum  and  the  occipital  protuberance  to  the 
anterior  fontanelle ;  it  measures  three  and  three-quarter  inches. 

In  order  that  the  diameters  of  the  fetal  head  may,  at  one  glance, 
be  compared  with  those  of  the  pelvis,  I  present  the  following  tables 
after  the  manner  of  Cazeaux : 


Diameters  of  the  pelvis, 
(in  inches). 

Antero-posterior. 

Transverse. 

Oblique. 

Sacro-cotyloid. 

Superior  Strait  

...4    to  4i  

...5    to  5£  

.4i  to  5   

33  to  41  ..  .. 

.4    to  5   

4    to  4J  

4    to  4J  

Kxcavation  

...4£  to  5£  

4J  to  4f  

.  41 

DIAMETERS  OF  THE  FETAL  HEAD. 

I  Occipito-mental 5  to  5£  inches. 

Longitudinal  Diameters....  J  Occipito-frontal 4  to  4f      *' 

(  Siib-occipito-bregmatic 3| 


Transverse  Diameters , 


Vertical  Diameters. 


(  Bi-parietal 3£  to  3| 

(  Bi-temporal.  3 

(  Trachelo-bregmatic  3J  to  3f 

Fron to-mental 3  to  4 


A  comparison  of  the  diameters  of  the  fetus  with  those  of  the  pelvis, 
will  be  found  of  much  utility,  enabling  the  practitioner  more  readily 
to  effect  a  correspondence  between  the  large  diameters  of  the  head  and 
the  long  diameters  or  axes  of  the  pelvis,  in  all  cases  where  such  a 
change  may  be  required.  From  an  investigation  of  these  measure- 
ments, it  will  be  seen  that  at  full  term,  the  fetus,  to  be  safely  and 
readily  expelled  must  present  one  end  of  its  long  diameter  (A  or  B,  Fig. 
16) ;  and  also,  that  if  its  occipito-raental  diameter  is  parallel  with  the 


THE    FETUS — ITS    DIVISIONS,    ETC.  59 

plane  of  the  inferior  strait,  delivery  will  be  impossible;  either  the  chin 
or  the  occiput  must  descend  first.  It  will  likewise  be  observed,  that 
the  most  favorable  position  for  the  expulsion  of  the  fetal  head,  is  to 
have  it  strongly  flexed  upon  the  body,  so  that  its  largest  diameter,  the 
occipito-mental,  shall  correspond  to  the  long  diameters  or  axes  re- 
spectively of  the  straits  and  cavity,  while  its  sub-  j?IG>  jy 
occipito-bregmatic  diameter,  shall  be  parallel  to  the 
plane  of  the  straits,  and  the  occiput  shall,  during  its 
passage,  correspond  to  one  extremity  of  an  oblique 
diameter,  until  the  rotation  ensues  which  places  the 
presenting  extremity  under  the  arch  of  the  pubis. 

Each  of  the  diameters  of  the   fetal  head  have  a 
circumference  assigned  to  them,  the  largest  of  which 
is  the  occipito-mental  circumference,  and  which  with 
the  occipito  frontal  or  horizontal  circumference,  are 
more    important    than   the    others,    because    during  A  B.  Bi-Parietai. 
labor  they  successively  come  into  relation  with  the   c  D-  Bi-Temporai. 
pelvic    parietes.      The    fronto-mental    circumference   passes   over  the 
chin,  cheeks,  and   forehead,  and   is  consequently  termed  by  several 
writers,  the  facial  circumference.     The  remaining  circumferences  are 
unimportant. 

The  other  diameters  of  the  fetus  are : 

1.  The  bis-aoromial  diameter,  extending  from  one  acromial  process 
to  the  other;  it  measures  four  and  a  half  inches. 

2.  The  dorso-sternal  diameter,  extending  from  the  vertebral  column 
through  to  the  sternum;  it  measures  three  and  a  half  inches. 

3.  The  bis-iliac  diameter,  extending  from  the  crest  of  one  ilium  to 
that  of  the  other ;  it  measures  three  and  three-quarter  inches. 

4.  The  bi-trochanterie  diameter,  extending  from  one  trochanter  to 
the  other;  it  measures  three  and  a  half  inches. 

The  movements  which  the  fetal  head  is  enabled  to  execute  with 
safety;  in  consequence  of  the  laxity  of  the  articular  ligaments  between 
the  head  and  vertebral  column,  must  not  be  forgotten.  In  head  pre- 
sentations the  shoulders  are  usually  expelled  so  soon  after  the  head 
has  passed,  that  accidents  are  rarely  met  with ;  but  in  breech  or  feet 
presentations,  or  in  cases  of  turning,  in  which  the  head  may  be  re- 
tained for  some  time  within  the  cavity  from  mal-position  or  otherwise, 
the  careless  or  unskilled  accoucheur  may,  by  the  employment  of  an 
ill-directed  force,  occasion  the  death  of  the  child. 

The  head  may  be  moved  in  four  different  directions,  termed  flexion, 


60  KING'S    I'X'LKCTIC    OBSTETRICS. 

cxt 'ii*loii,  lateral  inclination,  and  rotation;  and  the  extent  to  which 
these  movements  may  be  carried,  must  never  be  lost  sight  of. 

The  movement  of  flexion,  is  that  in  which  the  head  is  thrown  for- 
ward and  downward,  so  that  the  chin  is  depressed  upon  the  neck  or 
upper  part  of  the  sternum,  and  to  which  extent  this  motion  is  limited. 
By  it,  the  occipito-mental  diameter  of  the  head  is  made  part  of  the 
long  diameter  of  the  fetal  ovoid  or  ellipse.  This  movement  of  the 
head  should  never  be  forgotten,  as  when  it  is  incomplete,  or  there  ia 
too  early  a  departure  of  the  chin  from  the  breast,  during  the  passage 
of  the  head  through  the  pelvic  canal,  an  attention  to  it,  with  the 
proper  manipulation  to  restore  the  flexion,  as  hereafter  described,  will 
very  much  facilitate  the  expulsive  progress  of  the  head ;  but  a  want 
of  care  or  knowledge  in  this  matter  may,  in  these  instances,  render 
the  labor  tedious,  painful,  and  even  hazardous. 

The  movement  of  extension,  is  the  reverse  of  the  former;  the  head  is 
thrown  backward;  and  the  motion  is  limited  by  the  occiput  coming 
in  contact  with  the  back  of  the  neck.  This  motion  takes  place  in 
occipito-anterior  positions  of  the  head,  in  which  the  vertex  becomes 
placed  under  the  pubic  arch,  while  the  forehead,  face,  and  chin,  leav- 
ing their  previous  state  of  flexion,  pass  successively  along  the  arch  of 
the  sacrum,  coccyx,  and  perineum. 

The  movement  of  lateral  inclination  is  that  in  which  the  head  is 
thrown  to  one  side  or  the  other,  and  is  limited  by  the  side  of  the  head, 
meeting  with  the  corresponding  shoulder. 

The  movement  of  rotation  is  that  in  which  the  face  of  the  child  is 
turned  from  one  side  to  the  other.  All  the.other  motions  are  limited 
in  their  extent  by  an  opposing  obstacle,  but  in  this  last  there  is  none 
presented,  and  if  it  be  carried  too  far  the  life  of  the  child  will  be 
endangered.  I  have  met  with  several  cases  of  still-born  infants,  occa- 
sioned by  the  midwife  rotating  the  body  of  the  child  beyond  its  proper 
limits ;  and  instances  are  recorded  where  the  body  has  been  made  to 
turn  once  and  even  twice,  almost,  if  not  actually  twisting  off  the  neck. 
It  must  be  borne  in  mind  that  the  head  can  not  be  rotated  upon  the 
neck,  with  safety,  beyond  one-quarter  of  a  circle,  or  in  other  words, 
the  face  of  the  child  can  not  be  turned  to  the  right  or  left  beyond  the 
corresponding  shoulder;  and  this  applies  to  the  head  when  out  of  the 
pelvis,  and  the  body  within,  and  likewise  to  the  body  out  of  the  pelvis 
and  the  head  detained. 

One  thing  may  be  adverted  to  here, which  will  be  again  noticed  in 
another  place,  and  which  is,  that  pulling  the  body  of  the  child  for  the 
purpose  of  extracting  the  head,  or  pulling  with  the  forceps  applied  to 


THE    FEMALE    ORGANS    OF    GENERATION. 


61 


the  head,  the  body  not  being  expelled,  are  not  only  improper  but  ex- 
ceedingly culpable.  I  have  known  a  practitioner,  in  his  endeavor  to 
extract  the  head  with  the  forceps,  pull  so  forcibly  and  continuously,  as 
to  almost  tear  the  head  from  the  body,  at  the  same  time  lacerating  the 
soft  parts  of  the  mother  in  a  most  shocking  manner. 


CHAPTER  VIII. 


THE    FEMALE    ORGANS    OF    GENERATION. 


HAVING  referred  to  the 
osseous  portions  of  the  fe- 
male and  of  the  fetus,  in 
their  obstetrical  relations,  it 
becomes  necessary  to  briefly 
notice  the  soft  parts  which 
cover  them,  constituting  in 
the  adult  female,  the  organs 
of  generation,  and  which  are 
divided  into  external  and  in- 
ternal. The  external  organs, 
to  which  the  term  Pudendum 
is  applied,  are  situated  on 
the  exterior  of  the  pelvis, 
where  they  may  be  noticed 
by  the  eye,  and  comprise, 
1st.  The  mons  veneris ;  2d. 
The  vulva  and  its  parts;  3d. 
The  perineum.  The  inter- 
nal organs  are  more  deeply 
seated,  and  can  not  be  seen 
or  studied  except  by  dissec- 
tion ;  they  are,  1st.  The 
vagina;  2d.  The  uterus; 
3d.  The  Fallopian  tubes  and 
ligaments;  and  4th.  The 
ovaries. 

The  MONS  VENEEIS, 
or  supra-pubal  eminence,  is 


FIG.  18. 


THE  EXTERNAL  FEMALE  ORGANS  OF  GEHERA- 
TION. 

A.  The  Mons  Veneris. 

B.  The  Labia  Externa,  or  Labia  Pudendi. 

C.  The  Fourchette,  or  Posterior  Commissure  of  the  Vulva. 
D  D.  The  Perineum,  extending  from  the  Posterior  Com- 
missure of  the  Vulva  to  the  Anus. 

E.  The  Anus. 

F.  The  Clitoris. 

G.  The  Preputium  Olitoridis. 

H.  The  Nymphte,  or  Labia  luterna. 

I.  The  Vestibulutn. 

K.  The  Meat  us  Urinarius. 

L.  The  Hymen. 


62  KIN(;'s    KCLKCTIC    OIJSTKTinrs. 

a  triangular  space  situated  at  the  lower  part  of  the  hypogastrium, 
immediately  on  the  lore  part  of  the  pubis,  in  front  of,  and  just  above, 
the  symphysis  pubis.  It  presents  a  prominent  rotundity,  which  varies 
according  to  the  quantity  of  adipose  matter  deposited,  and  of  which 
it  is  principally  composed ;  it  is  more  prominent  in  young  and  vig- 
orous virgins  than  in  mothers  and  aged  females,  and  is  said  to  be  much 
more  so  in  young  females  the  natives  of  tropical  climates.  The  cutis 
or  skin  which  covers  this  part  is  smooth  in  early  life,  but  becomes 
covere  1  with  short  curled  hair  or  capilli  at  maturity,  and  is  supplied 
with  numerous  sebaceous  follicles;  a  straight  long  hair  is  said  to  be 
indicative  of  sterility,  and  also  of  a  lack  of  energy  of  the  reproductive 
organs.  Through  the  adipose  and  cellular  tissue,  are  ramifications  of 
some  branches  of  the  external  pudic  vessels  and  nerves,  and  in  it  are 
distributed  some  fibers  of  the  round  ligaments  of  the  uterus. 

The  uses  of  the  mons  veneris  during  copulation  are  not  satisfactorily 
ascertained,  though  it  is  said  to  be  more  elevated  when  the  female  is 
laboring  under  sexual  excitement,  and  immediately  previous  to  men- 
struation. Moreau  states,  that  in  parturition,  owing  to  the  extensi- 
bility of  the  skin,  and  laxity  of  the  cellular  tissue  contained  within  it, 
it  assists  in  augmenting  the  size  of  the  vulva.  This  part  is  sometimes 
attacked  with  inflammations  and  abscesses  which  prove  exceedingly 
painful,  and  may  suffer  from  the  various  forms  of  disease  common  to 
the  tissues  entering  into  its  formation. 

The  VULVA  is  the  slit,  or  longitudinal  fissure  (fissura  vulvce,  or 
genital  fissure) ,  which  extends  from  the  mons  veneris  superiorly,  along 
the  median  line  to  the  perineum  inferiorly.  The  orifice  of  the  vulva 
serves  as  an  entrance  to  some  of  the  internal  organs;  it  varies  in  ex- 
tent in  different  persons;  is  very  small  in  infancy,  small  and  narrow 
in  girls,  of  greater  width  and  extent  in  women,  and  during  parturition 
distends  to  a  size  which  admits  of  the  free  passage  of  the  child  through 
it.  After  copulation  its  size  is  usually  double  that  of  the  vagina! 
orifice;  and  in  women  who  have  borne  many  children,  or  who  have 
had  laceration  of  the  perineum,  it  most  commonly  remains  quite 
large. 

Along  the  lateral  portions  of  the  vulva  are  two  rounded  folds,  or 
oblong  eminences,  or  lips,  which  extend  in  a  longitudinal  direction 
from  the  mons  veneris  to  the  posterior  part  of  the  vulva;  these  are 
called  the  LABIA  MAJORA,  labia  externa,  or  labia  pudendi.  As 
they  proceed  from  before  backward,  they  diminish  in  thickness,  which 
renders  them  more  prominent  above  than  below;  their  superior  ex- 


THE  FEMALE  ORGANS  OF  GENERATION.  63 

tremity  is  adherent,  the  inferior  being  free  and  rounded.  Externally, 
the  labia  majora  are  covered  with  the  common  skin,  on  which  a  few 
hairs  may  be  found,  and  which  is  supplied  with  numerous  sebaceous 
follicles;  internally,  it  is  covered  with  a  beautifully  fine,  smooth,  and 
sensitive  mucous  membrane,  of  a  florid  color  in  young  persons,  but 
which  is  lost  on  the  approach  of  age.  The  inner,  or  mucous  surface, 
is  supplied  with  glands  that  secrete  a  fluid  preventing  an  adhesion  of 
these  parts,  as  well  as  protecting  them  from  the  effects  of  friction. 
By  their  approximation,  the  labia  majora  cover  and  protect  the  in- 
ternal parts  from  the  air  and  external  agencies;  and  during  parturition, 
when  the  child  is  about  to  be  expelled,  by  their  elongation  and  almost 
entire  disappearance,  they  increase  the  capaciousness  of  the  vulva. 
They  may  be  attacked  with  inflammation,  abscess,  hernia,  serous  in- 
filtration, or  other  diseases,  which  sometimes  interfere  with  their 
functional  activity,  or  occasion  various  accidents. 

The  point  of  union  of  the  labia  majora,  at  their  upper  or  anterior 
extremity,  at  the  symphysis  pubis,  forms  the  anterior  commissure  of 
the  vulva;  and  at  their  lower  or  posterior  extremity  they  form  a  kind 
of  bridle  at  the  anterior  edge  of  the  perineum,  called  the  FOUK- 
CHETTE,  frcenum,  or  posterior  commissure  of  the  vulva,  which  is 
sometimes  slightly  lacerated  during  first  labors,  but  which  occurrence 
causes  no  trouble.  The  posterior  commissure  is  the  most  dense  and 
resisting  point  of  the  vulva,  not  yielding  without  difficulty. 

On  separating  the  labia  majora,  we  observe  several  other  parts;  the 
NYMPH.ZE,  labia  internet,  or  labia  minora,  which  are  two  mem- 
branous folds,  located  between,  and  running  parallel  with,  the  labia 
majora,  and  which  extend  from  the  anterior  commissure  to  about  the 
genital  fissure;  they  are  formed  of  cellular,  as  well  as  spongy  tissues, 
covered  with  mucous  membrane,  and  contain  many  vessels  and  nerves 
which  render  them  highly  sensitive.  Their  superior  edge  is  coherent, 
the  inferior  loose;  and  a  little  below  the  anterior  commissure  of  the 
vulva  they  unite,  the  anterior  extremity  passing  around  the  clitoris  so 
as  to  form  a  hood,  or  prepuce  to  it,  while  the  posterior  is  lost  in  the 
corresponding  labium  pudendi.  In  young  persons,their  color  is  lively 
red,  they  are  firm,  and  their  surface  is  not  corrugated,  but  smooth;  in 
women  who  have  had  children  they  become  darker  and  wrinkled. 
Females  of  a  phlegmatic  temperament,  and  especially  those  laboring 
under  leucorrhea,  have  them  pale  and  flaccid ;  and  in  brunettes  they 
are  dark,  granulated,  and  sometimes  quite  long.  They  are  furnished 
with  a  sebaceous  substance,  which,  if  allowed  to  accumulate  in  quantity, 
occasions  a  disagreeable  fetor. 


64  KI.NC's     KCLKCTIC    OHSTKTHICS. 

In  early  life  the  nymphse  are  so  long  as  to  project  beyond  the  ex- 
ternal lips,  or  labia  majora,  which,  however,  usually  disappears  at 
puberty.  Occasionally,  the  labia  minora  have  projected  so  far  as  to 
produce  much  inconvenience,  requiring  an  operation  for  their  removal ; 
and  among  the  South  Africans,  especially  the  Bochisman  women,  this 
elongation  is  found  in  an  excessive  degree,  extending  to  eight  or  ten 
inches  below  the  margin  of  the  labia,  forming  what  has  been  named 
the  apron  of  the  Hottentots. 

The  uses  of  the  nymphse  are  unknown,  although  they  are  supposed 
to  add  to  the  voluptuousness  of  copulation,  and  to  amplify  the  vulva 
during  parturition,  by  becoming  distended  or  effaced ;  this  last  view, 
however,  does  not  agree  with  my  own  observations,  as  I  have  repeat- 
edly ascertained  their  presence  during  the  passage  of  the  fetal  head 
into  the  world. 

The  CLITORIS  is  situated  at  the  superior  and  median  part  of  the 
vulva,  at  the  junction  or  origin  of  the  labia  minora,  and  just  below 
the  anterior  commissure  of  the  vulva.  It  is  a  small  red  projection, 
bearing  some  resemblance  to  the  male  penis,  having  two  corpora  cav- 
ernosa,  which  are  attached  by  crura  to  the  rami  of  the  pubes  and  ischia, 
a  spongy,  cellular  tissue,  somewhat  similar  to  the  corpus  spongiosum 
in  the  male,  two  erector  muscles  inserted  into  the  above  named  crura 
rendering  the  organ  erectile,  and  is  surrounded  with  a  fold  of  the  in- 
ternal mucous  membrane  of  the  labia,  which  forms  the  prepuce,  or 
preputium  clitoridis.  It  is,  however,  imperforate,  being  without  a 
canal,  or  urethra.  At  its  external  termination  is  a  round,  red  protu- 
berance, which,  from  its  shape,  has  received  the  name  of  glans  clitoridis. 

The  clitoris  is  supplied  with  arteries  and  veins  from  several  sources, 
and  its  nerves,  which  chiefly  arise  from  the  sacral  plexus  [branches 
of  the  pudic],  endow  it  with  intense  erotic  sensibility.  Its  length  is 
variable,  and  when  uncommonly  long  or  hypertrophied,  has  sometimes 
occasioned  doubts  as  to  the  sex  of  the  individual.  It  is  of  no  service 
in  parturition,  but  is  considered  as  the  principal  seat  of  venereal 
pleasure  in  the  female ;  the  excision  of  this  organ  in  the  adult  female 
very  much  lessens  the  voluptuousness  of  sexual  congress;  and  its 
titillation  alone  will  give  completion  to  the  venereal  orgasm,  as  in  in- 
stances of  masturbation.  In  infants,  this  organ  presents  an  apparent 
excess  of  size,  projecting  beyond  the  vulva,  and  which  is  owing  to  the 
want  of  development  of  the  proximate  organs,  especially  of  the  labia 
majora. 

The  VESTIBULE  is  a  triangular  space  or  depression,  about  an 
inch  in  length,  having  the  clitoris  above,  the  meatus  urinarius  or  ori- 


THE  FEMALE  ORGANS  OP  GENERATION.  65 

fice  of  the  urethra  below,  and  the  nymphse  laterally.  The  lower,  or 
inferior  portion  of  this  depression, is  divided  by  a  line  or  raphe,  which 
•  can  be  readily  felt 'with  the  point  of  the  finger,  and  which  leads  di- 
rectly to  the  orifice  of  the  urethra.  It  is  supplied  with  numerous 
mucous  glands.  Immediately  beneath  the  vestibulum  may  be  recog- 
nized, situated  on  a  line  with  the  top  of  the  pubic  arch,  a  small  bulb- 
ous projection  or  cushion,  which  incloses  the  orifice  of  the  urethra. 
A  knowledge  of  this  arrangement  will  render  the  catheterism  of  the 
female  an  easy  operation. 

The  FEMALE  URETHRA  is  a  slightly  curved  canal,  from  one  to 
two  inches  in  length.  It  is  larger  and  more  dilatable  than  that  of  the 
male,  and  passes  directly  beneath  and  behind  the  symphysis  pubis  in 
an  oblique  direction,  upward  and  backward,  having  its  concavity  up- 
ward, on  the  pubic  side,  and  its  convexity  downward,  on  the  vaginal 
side.  During  labor  or  parturition,  the  urethra  becomes  elongated,  and 
its  direction,  as  well  as  that  of  its  orifice,  changes,  so  as  to  create  diffi- 
culty in  the  introduction  of 'the  catheter.  For  instance,  distension  of 
the  bladder  with  urine,  distension  of  the  vagina  by  the  presenting 
parts,  or  the  elevation  of  the  uterus,  may  carry  the  urethral  canal 
high  upward,  and  sometimes  thrust  it  against  the  pubes,  so  that  its 
orifice  will  be  brought  behind  the  symphysis  pubis ;  in  such  cases,  the 
sound  or  catheter  must  be  introduced  behind  and  parallel  to  the  sym- 
physis. The  urethra  is  lined  internally  with  mucous  membrane,  the 
folds  of  which  usually  run  longitudinally  and  not  transversely. 

The  external  orifice  of  the  urethra,  called  the  meatus  urinarius,  is 
situated  below  the  vestibule,  and  immediately  above  the  vaginal  open- 
ing; it  is  irregularly  round,  and  is  more  constricted  than  the  upper 
portion  of  the  urethral  canal.  A  membranous  swelling,  or  cushion, 
abundantly  supplied  with  numerous  follicles,  surrounds  it;  and  in 
ordinary  cases,  where  the  introduction  or  the  catheter  is  necessary, 
after  having  found  this  raised  cushion,  which,  as  already  stated,  is  at 
the  lower  part  of  the  vestibule,  directly  under  the  symphysis  pubis, 
the  orifice  will  be  discovered  in  the  center  of  it.  The  point  of  the 
catheter  should  be  directed  perpendicularly  to  the  surface  of  the  ves- 
tibule, introduced  within  the  orifice,  then  by  depressing  the  handle,  the 
point  will  turn  upward  behind  the  pubis  and  toward  the  bladder. 
This  tubercle  or  caruncle  of  the  urethra  varies  in  its  development, 
the  orifice  being  sometimes  very  thin,  merely  membranous,  and  at 
others  very  patulous  and  funnel  shaped. 

In  instances  where  from  long-continued  pressure  of  the  child's  head, 
or  from  other  causes,  the  practitioner  is  unable  to  detect  the  meatus 
5 


B6  KING'S  ECLECTIC  OBSTETRICS. 

urinarius,  and  it  is  absolutely  necessary  that  the  bladder  should  be 
evacuated  to  avoid  its  rupturing,  or  the  probable  formation  of  a 
fistulous  passage  between  it  and  the  vagina,  it  may  be  necessary  • 
for  the  practitioner  to  expose  the  parts  to  sight,  in  order  to  in- 
troduce the  catheter;  indeed,  it  is  his  duty  to  do  so;  but  under 
ordinary  circumstances  the  patient  should  never  be  exposed  for  the 
operation. 

The  urethra  may  be  so  severely  pressed  by  the  fetal  head  as  to 
occasion  sloughing,  resulting  in  urethro-vaginal  fistula,  which  is  a 
very  difficult  malady  to  remove;  and  in  operations  with  the  forceps 
or  crotchet,  the  practitioner  sho'uld  be  extremely  cautious  not  to  bruise 
or  lacerate  this  canal,  as  it  is  almost  certain  to  result  in  permanent 
stillicidium  of  urine.  The  urethra!  mucous  membrane  is  subject  to 
prolapsus,  tumefaction,  and  occasionally  polypus  growths. 

The  HYMEN,  also  termed  the  virginal  valve,  vaginal  valve,  fios 
virginitatis,  claustrum  virginale,  etc.,  is  a  membranous  fold  formed  by 
the  mucous  membrane  of  the  genital  surface.  It  is  situated  about 
half  an  inch  within  the  vulva,  at  the  orifice  of  the  vagina  (ostium 
vagince),  which  it  closes  more  or  less  perfectly,  and  is  usually  in  the 
shape  of  a  crescent,  with  its  convexity  downward  and  adhering,  and 
its  concavity  upward  and  detached.  Sometimes  it  is  oval  from  right 
to  left,  or  circular,  with  one  or  more  openings  which  allow  the  various 
secretions  and  discharges  from  the  vagina  and  uterus  to  pass  out; 
occasionally,  it  is  imperforate,  preventing  the  egress  of  these  dis- 
charges". Ordinarily,  the  hymen  is  quite  thin  and  delicate,  being 
ruptured  by  the  slightest  causes ;  sometimes  it  is  soft  and  lax,  yielding 
without  rupturing;  and  instances  have  occurred  in  which  it  was  so 
firm  as  to  present  an  obstacle  to  copulation,  or  to  embarass  the 
process  of  parturition;  to  remedy  which,  it  has  been  found  necessary 
to  make  a  circular  or  crucial  incision  in  it. 

The  uses  of  this  membrane  are  not  well  defined,  nor  can  they  be 
of  much  consequence,  since  it  is  lost  daily  without  injury.  The  pres- 
ence of  the  hymen  has  long  been  regarded  as  a  sign  of  virginity,  but 
when  we  reflect  that  it  is  sometimes  readily  ruptured  in  females  of 
undoubted  chastity,  even  in  the  acts  of  laughing,  coughing,  sneezing, 
lifting,  etc.,  and  again  that  it  has  been  found  entire  at  the  time  of 
parturition,  most  convincing  proof  is  afforded,  that,  as  an  emblem 
of  virginity,  this  membrane  can  not  be  depended  upon  under  any 
circumstances  whatever;  for  its  absence  affords  no  evidence  that 
sexual  intercourse  has  taken  place,  nor  does  its  presence  prove  the 
condition  of  chastity.  It  is  often  destroyed,  during  infancy,  by  care- 


THE    FEMALE    ORGANS    OF    GENERATION.  67 

less  nurses  who  rub  these  parts  roughly  with  a  coarse  towel.  I  have 
met  with  seven  instances  only,  of  firm  and  imperforate  hymen  in 
which  it  was  impossible  for  the  nuptial  rites  to  be  consummated, 
and  one  in  which  it  was  present  at  the  parturient  period,  and  in  each 
of  which  the  difficulty  was  removed  by  the  bistoury. 

Along  the  circumference  of  the  orifice  of  the  vagina,  are  several 
small,  flat,  or  rounded  reddish  tubercles,  commonly  numbering  from 
two  to  four,  occasionally  five  or  six.  Sometimes  they  are  pale,  or 
livid,  and  vary  in  firmness.  They  exist  in  pairs,  the  two  posterior 
being  generally  larger  and  longer  than  the  anterior.  These  are  termed 
the  CARUNCUL^E  MYRTIFORMES,  and  are  considered  by  some 
anatomists  as  the  remains  of  the  ruptured  hymen,  while  others  view 
them  as  existing  independent  of  this  membrane.  I  have  in  three 
instances,  witnessed  the  unrupturcd  hymen  simultaneously  with  the 
presence  of  the  carunculse.  As  they  disappear  during  the  expulsion 
of  the  fetus,  they  may  probably  be  designed  for  enlarging  the  capacity 
of  the  vulva,  thereby  diminishing  the  risk  of  severe  contusion  or 
laceration.  When  they  become  so  large  as  to  cause  unpleasant  symp- 
toms they  may  be  removed  by  the  scissors. 

Between  the  posterior  commissure  of  the  vulva,  or  fburchette,  and 
the  hymen  and  the  external  orifice  of  the  vagina,  is  a  space  or  depres- 
sion bearing  some  resemblance  to  the  cavity  of  a  small  boat,  which  is 
called  the  FOSSA  NAVICULARIS,  or  concha.  Its  greatest  extent 
is  six  lines,  or  half  an  inch.  It  is  found  in  girls  and  in  women  who 
have  not  given  birth  to  children,  but  is  usually  ruptured  in  a  first  con- 
finement by  the  efforts  made  to  expel  the  fetal  head,  and  which  is  fol- 
lowed by  no  serious  consequences  unless  more  or  less  of  the  perineum 
be  likewise  involved.  It  is  the  most  inferior  part  of  the  vulva,  and 
hence  becomes  a  receptacle  for  vaginal  and  uterine  discharges ;  inflam- 
mation and  syphilitic  ulcerations  are  frequently  located  there  among 
public  women,  which  occasion  obstinate  and  intractable  difficulties, 
not  easy  to  cure. 

The  PERINEUM  proper,  includes  the  whole  of  the  space  between 
the  coccyx  and  the  pubes,  including  the  terminal  orifices  of  the  urinary, 
generative,  and  digestive  apparatus;  but  in  Obstetrics,  by  the  term 
perineum,  is  meant  the  space  lying  between  the  posterior  commissure 
of  the  vulva  and  the  anus.  It  is  from  an  inch  to  an  inch  and  a  half  in 
length,  and  presents  on  its  external  surface,  on  the  mesial  line,  a  .prom- 
inent, hard  ridge,  which  is  termed  the  raphe  of  the  perineum.  Exter- 
nal ty,the  ]>erineum  is  covered  with  the  skin;  internally,  it  consists  of 


68  KING'S  ECLECTIC  OJ:STJ:TKICS. 

adipose  cellular  tissue,  of  fascia,  aud  of  several  muscles.  In  some 
females  it  is  thick,  hard,  and  resisting;  in  others  it  is  thin,  soft,  and 
easily  dilated ;  conditions  which  render  labor  tedious  or  otherwise,  by 
retarding  the  passage  of  the  fetal  head  when  rigid  and  unyielding,  or 
allowing  ib  to  pass  by  a  ready  dilatation. 

In  the  last  stage  of  labor,  the  perineum  usually  offers  more  or  less 
resistance,  but  eventually  becomes  thinner,  elongates,  and  extends, 
even  to  four  or  five  inches,  thus  affording  a  passage  for  the  child ;  and  it 
is  at  this  period,  when  the  head  is  passing,  that  it  becomes  occasionally 
lacerated,  or  more  rarely,  perforated  through  its  center.  This  acci- 
dent, however,  may  generally  be  avoided,  by  supporting  the  perineum 
with  the  hand,  making  such  firm  but  moderate  pressure  as  will  pre- 
vent the  head  from  advancing  too  rapidly,  and  which,  at  the  same 
time,  will  allow  the  tissues  an  opportunity  to  acquire  the  proper  degree 
of  extensibility.  Excessive  and  injudicious  support  will  undoubtedly 
effect  more  mischief  than  benefit.  The  condition  of  the  perineum 
should  never  be  overlooked  by  the  practitioner,  as  it  frequently  pre- 
sents an  obstacle  to  delivery  far  greater  than  the  os  uteri,  the  straits, 
and  the  vagina  together,  owing  to  its  unyielding  resistance ;  and 
a  labor  which,  under  ordinary  circumstances,  would  be  finished  in 
from  fifteen  to  thirty  minutes  after  the  head  has  reached  this  point, 
may  be  continued  for  several  hours.  This  rigid  'condition  of  the 
perineum  is  often  brought  on  by  excessive  meddling,  frequent  exam- 
inations, etc.  I  have  overcome  several  instances  of  obstinate  resist- 
ance, in  a  very  short  time,  by  relaxing  the  parts  by  means  of  a  process 
of  dilatation,  which  may  be  produced  by  sweeping  the  finger  through 
the  posterior  commissure  of  the  vulva.  Rigidity  of  the  perineum  is  a 
condition  which  frequently  retards  the  completion  of  labor ;  support  to 
the  parts  as  usually  applied  is  a  feeble  agent  in  overcoming  it;  the 
sweeping  movement,  however,  if  applied  at  frequent  intervals,  for  a 
brief  period,  will,  as  a  rule,  result  in  complete  muscular  relaxation. 


CHAPTER   IX. 

THE   INTERNAL   ORGANS    OF    GENERATION. 

THE  internal  organs  of  generation,  belonging  to  the  female,  are,  as 
previously  remarked,  the  vagina,  the  uterus  and  its  appendages,  the 
Fallopian  tubes,  ligaments,  and  ovaries  (Fig.  19). 

the  VAGINA  is  a  cylindrical  membranous  canal,  which  con- 
nects the  internal  with  the  external  organs  of  generation;  it  is 


INTERNAL    ORGANS    OF    GENERATION. 


69 


located     in     the     pelvic    cavity,  FlG- 

being  posterior  to  the  bladder 
and  urethra,  and  anterior  to  the 
rectum.  Its  direction  is  nearly 
coincident  with  the  axis  of  the 
pelvis,  which  gives  a  curved  form 
to  it,  the  concavity  of  which,  is 
on  its  anterior  or  pubic  surface, 
and  the  convexity  on  its  posterior  or 
rectal  surface.  The  walls  of  the 
vagina  are  soft  and  yielding,  and 
slightly  flattened  from  before  back- 
ward— the  anterior  wall  being 
shorter  than  the  posterior.  In  well 
formed  women  its  length  is  five  or 
six  inches,  and  its  width  one; but 
this  usually  varies  according  to  age, 
and  the  different  circumstances  of 
life.  In  girls,  it  is  longer  and 
narrower  than  in  married  women, 
and  especially  those  who  have 
borne  children ;  and  in  African 
women  it  is  -longer  and  wider 
than  in  European.  The  middle 
portion  of  the  vaginal  tube  is  larger  than  at  the  extremities,  and  the 
lower  or  inferior  orifice  is  more  contracted  than  at  its  upper  or  superior 
extremity.  The  walls  of  the  vagina  are  generally  in  contact,  when 
undisturbed.  As  females  advance  in  years,  the  vagina  gradually  con- 
tracts its  dimensions  to  nearly  those  found  in  young  girls.  It  is  com- 
posed of  a  fibrous  and  mucous  membrane;  the  first  is  placed  exter- 
nally, and  consists  of  condensed  cellular  tissue,  highly  elastic,  and  of 
.a  reddish  color. 

The  external  surface  of  the  vagina  is  united,  in  front  to  the  bas-fond 
of  the  bladder  and  to  the  urethra,  by  cellular  tissue,  which  becomes 
denser  as  it 'approaches  the  vulva;  behind,  to  the  rectum,  by  similar 
cellular  tissue,  but  which  is  less  dense  than  in  front;  laterally,  to  the 
broad  ligaments  and  ureters  above,  and  below  to  the  umbilical  arteries, 
the  sacral  plexuses,  the  hypogastric  vessels,  the  levator  muscles  of  the 
anus,  and  the  pelvic  cellular  tissue;  and  superiorly,  above  and  behind, 
by  a  double  fold  of  peritoneum. 

The  internal  surface  of  the  vagina  is  divided  into  an   anterior  and  a 


THE    INTERNAL    FEMALE    GENITAL 
ORGANS. 

A.  The  Uterus,  seen  on  its  Anterior  Face. 

B.  The  Intra-vaginal  portion  of  the  Neck  of  the 

Uterus. 

C  C.  The  Fallopian  Tubes. 
D.  The  flmbriated  Extremities  of   the  Fallipoan 

Tubes. 

E  E.  The  Ovaries. 
F.  The  Ligament  of  the  Ovary. 
G  G.  The  round  Ligaments. 
H.  The  Vagina  laid  opun. 

On  the  right  the  fimbriated  extremity  of  the 
Fallopian  Tube  is  seen  applied  to  the  Ovary. 


70  KIND'S    r.«  LECTIC  OBSTETRICS. 

posterior  wall.  In  the  center  of  each  of  these  parietes  is  a  longitudinal 
line  or  ridge,  the  one  on  the  anterior  being  more  distinct  and  prominent 
than  that  on  the  posterior  wall;  these  ridges  are  called  columnar  vaginae, 
or  columns  of  the  vagina — one,  the  anterior  column  of  the  vagina, 
the  other,  the  posterior  column  of  the  vagina.  One  or  two  tubercles 
are  generally  found  at  their  inferior  terminations.  These  columns  are 
intersected  at  right  angles  by  transverse  parallel  ruga?,  folds  or 
wrinkles,  which  become  more  prominent  and  approximate  more  closely 
as  they  advance  toward  the  vulva;  these  ruga?,  however,  do  not  con- 
stantly exist ;  they  are  more  distinctly  marked  in  girls  and  in  aged 
women ;  and  during  pregnancy,  as  well  as  for  a  short  period  after  par- 
turition, they  are  nearly  eifaced.  Some  writers  consider  them  as  aids 
to  the  enlargement  of  the  vagina  during  labor ;  others,  that  they  assist 
in  the  elongation  which  it  undergoes  during  pregnancy,  caused  by  the 
ascent  of  the  uterus ;  and  others  again,  that  by  multiplying  the  points  of 
contact  between  the  vaginal  walls  and  the  male  organs,  the  voluptuous- 
ness of  coition  is  increased. 

The  superior,  internal,  or  upper  extremity  of  the  vagina,  is  attached 
around  the  upper  part  of  the  neck  of  the  uterus,  being  a  little  higher 
behind  than  in  front.  The  peculiar  manner  by  which  it  embraces  the 
neck,  gives  rise  to  a  circular  fissure  or  groove,  to  which  the  name  cul- 
de-sac  has  been  applied ;  the  one  in  front,  being  termed  the  anterior 
cul-de-sac;  that  behind,  and  which  is  more  distinctly  marked,  the  pos- 
terior cul-de-sac.  These  culs-de-sac  are  of  greater  or  less  depth,  accord- 
ing to  the  projection  of  the  neck  of  the  uterus.  This  portion  of  the 
vagina  is  in  immediate  contact  with  the  peritoneum,  which  separates 
it  from  the  abdominal  cavity ;  and  it  is  here  where  injuries  are  most 
commonly  inflicted  by  the  use  of  instruments,  often  resulting  in  in- 
flammation and  death ;  hence,  when  operations  are  demanded,  great 
care  should  be  observed  by  the  operator. 

The  inferior,  external,  or  lower  extremity  of  the  vagina,  sometimes 
termed  the  external  or  vuVvar  orifice,  which  terminates  belowr  the 
urethra,  is  narrowed  at  its  entrance,  and,  in  the  virgin}  is  usually  par- 
tially closed  by  the  hymen. 

The  internal  parietes  of  the  vagina  are  composed  of  a  mucous  mem- 
brane, which  is  the  continuation  of  that  of  the  vulva,  and  the  internal 
membrane  of  the  uterus;  inferiorly,  this  membrane  is  of  a  red  or  ver- 
million  tinge,  and  superiorly  it  has  a  whitish  or  grayish  appearance. 
Occasionally,  it  presents  posteriorly,  bluish  or  livid  spots,  which  are 
more  or  less  irregular.  It  is  furnished  with  numerous  mucous  follicles, 
the  secretions  from  which  constantly  keep  the  parts  during  health,  and 


INTERNAL    ORGANS    OF    GENERATION.  71 

especially  during  parturition,  in  a  state  of  lubricity.  If  this  organ 
becomes  dry  and  inflamed,  while  labor  is  progressing,  a  rigid  and  un- 
yielding condition  of  it  ensues,  which  must  necessarily  occasion  much 
distress  to  the  patient;  hence  the  importance  of  examining  during 
labor,  as  seldom  as  possible,  because  the  frequent  introduction  of  the 
finger  into  the  vagina  not  only  removes  the  moisture  of  the  parts,  but 
likewise  irritates  them ;  beside  frequent  touchings  are  useless,  deleteri- 
ous, and  immodest. 

The  part  surrounding  the  orifice  of  the  vagina,  is  termed  the  bulb 
of  the  vagina  or  the  plexus  retiformis;  it  is  a  dense,  compact,  erectile 
spongy  tissue,  somewhat  resembling  that  of  the  corpus  spongiosum 
urethne,  of  a  grayish  or  bluish  color,  about  an  inch  in  breadth,  and 
two  or  three  lines  in  thickness.  During  the  venereal  orgasm,  it  con- 
tracts the  vaginal  cavity,  and  thus  increases  its  resistance.  The 
sphincter  vagince  or  constrictor  vagince  muscle  is  formed  by  some  mus- 
cular fibers  on  the  outside  of  this  spongy  tissue ;  it  contracts  the 
vaginal  orifice,  and  depresses  the  clitoris. 

The  arteries  of  the  vagina  come  from  the  internal  iliac ;  its  veins, 
which  are  numerous,  form  a  kind  of  net-work  called  plexiform,  and 
flow  into  the  hypogastrics ;  its  nerves  arise  from  the  sacral  plexus, 
and  its  lymphatics  are  lost  in  the  hypogastric  lymphatic  plexus.  The 
contractility  of  the  vagina  is  of  the  peculiar  elastic  character  common 
to  all  cellular  structure.  As  soon  as  the  fetus  has  been  expelled,  this 
organ  resumes  its  natural  condition  in  a  very  short  time,  except  in 
cases  where  the  head  has  been  confined  in  the  cavity  for  a  longer 
period  than  usual,  when  its  contraction  will  not  take  place  for  one  or 
two  hours ;  and  the  hand  may  be  very  readily  introduced  within  it  for 
some  hours  after  delivery. 

The  vagina  serves  as  a  medium  through  which  external  bodies  may 
pass  toward  the  uterus,  as  during  copulation,  and  also  through  which 
the* uterine  contents  and  vaginal  secretions  may  pass  oif,  as  the  fetus, 
menses,  etc.  It  is  subject  to  inflammation,  uleeration,  eversion,  inver- 
sion, etc.,  the  history  and  treatment  of  which,  more  properly  belong 
to  a  treatise  on  "  Diseases  of  Women." 

The  UTERUS,  or  womb,  is  a  hollow  organ,  whose  principal  func- 
tions are  to  receive  the  impregnated  ovum,  as  it  escapes  from  the 
Fallopian  tube,  to  assist  in  its  nourishment,  growth,  and  preservation, 
until  the  parturient  period  arrives,  and  then  to  act  as  the  principal 
agent  in  forwarding  its  expulsion.  It  is  a  yestative  not  a  generative 
organ. 


72  KING'S  ECLECTIC  OBSTETRICS. 

In  shape,  the  uterus  is  conical  or  pyriform,  usually  described  as 
resembling  a  pear  flattened  from  before  backward,  with  its  base  turned 
upward,  and  its  apex  downward.  It  is  situated  obliquely  in  the  pelvic 
cavity,  below  the  small  intestines,  between  the  bladder  and  rectum, 
and  above  the  vagina;  and  is  retained  in  its  position  by  the  round  and 
broad  ligaments,  and  the  vagina.  Its  axis  or  long  diameter  very 
nearly  corresponds  with  the  axis  of  the  superior  strait.  In  very  young 
females  its  base  is  below  the  superior  strait ;  in  adults  it  is  nearly  on  a 
level  with  it. 

In  childhood  it  is  quite  small,  but  rapidly  increases  in  growth  to- 
ward puberty  and  adult  age,  and  after  the  period  of  child-bearing,  it 
diminishes  to  nearly  its  infantile  size.  Its  average  length,  in  the  adult 
woman,  is  two  and  a  quarter  to  three  inches ;  its  breadth  at  the  fundus, 
one  and  a  third  to  two  inches,  and  toward  the  neck,  including  the  os 
tincse,  one  inch  to  one  and  a  half  inches;  and  its  thickness  from  eight 
to  twelve  lines,  or  from  four  to  six  lines  for  each  of  its  walls. 

Immediately  previous  to  menstruation  and  during  that  term,  it 
usually  becomes  greatly  augmented  in  volume,  which  may  be  mis- 
taken for  the  commencement  of  a  pregnancy.  Its  weight,  in  the 
virgin  female,  is  seven  or  eight  drachms,  and  in  those  who  have  had 
children,  from  twelve  drachms  to  an  ounce  and  a  half,  while  in  the 
aged  female  it  dwindles  to  one  or  two  drachms. 

The  uterus  is  divided  into  three  parts:  1,  the  base  or  fundus  uteri, 
which  is  only  a  few  lines  high,  being  confined  to  all  that  portion  which 
rises  above  the  insertion  of  the  Fallopian  tubes;  2,  the  body  or  corpus 
uteri,  which  is  the  largest  division  of  the  uterus,  and  includes  all  that 
part  of  the  organ  situated  between  the  fundus  and  the  neck,  or  con- 
tracted portion ;  3,  the  neck  or  cervix  uteri,  which  is  the  contracted 
and  elongated  portion  found  below  the  body,  about  an  inch  in 
length,  and  which  is  embraced  by  the  vagina,  forming  in  its  cavity  a 
projection  of  four  to  six  lines,  at  the  extremity  of  which  is  an  open- 
ing, termed  os  tincoe,  from  its  fancied  resemblance  to  the  mouth  of  the 
tench  fish,  also  called  os  uteri  externum.  The  orifice, at  the  junction 
of  the  uterine  cavity  with  the  superior  extremity  of  the  canal  of  the 
cervix,  is  termed  os  uteri  internum.  The  uterine  sound  is  frequently 
checked  in  its  progress  to  the  uterine  cavity  at  this  point,  from  con- 
traction, and  generally  with  more  or  less  pain ;  but  if  the  instrument 
be  held  steadily,  pressing  lightly  upon  the  parts,  the  contraction  will 
yield,  and  the  sound  pass  onward.  But  this  should  not  be  persisted 
in  when  severe  pain  persists. 

Generally,  the  uterus  is  slightly  inclined  to  the  right,  sometimes  to 


INTERNAL   ORGANS    OF    GENERATION.  73 

the  left,  or  backward.  Its  position,  however,  is  not  constajit,  being 
determined  by  its  own  condition,  as  well  as  that  of  the  neighboring 
parts.  Thus  females, in  whom  the  vagina  is  short,  will  have  the  axis 
of  the  uterus  approximating  that  of  the  inferior  strait;  sometimes  the 
fundus  is  thrown  so  far  forward  that  the  anterior  wall  is  the  most  in- 
ferior part,  constituting  an  anteversion;  at  other  times  it  may  be  the 
reverse  of  this,  the  fundus  being  thrown  in  the  hollow  of  the  sacrum, 
and  the  neck  behind  the  symphysis  pubis,  producing  a  retroversion  ; 
or,  the  fundus  may  be  thrown  to  one  side  of  the  pelvic  cavity,  with 
the  neck  to  the  opposite  side,  which  is  termed  lateral  version;  and 
again,  the  body  of  the  uterus  may  be  bent  on  the  neck,  either  behind 
or  in  front,  constituting  an  anteftexion  or  retrqflexion. 

We  distinguish,  in  the  uterus,  an  external  and  an  internal  surface. 
The  EXTERNAL  SURFACE  is  divided  into  an  anterior  and  a 
posterior  face,  a  superior  and  two  lateral  borders,  two  superior  angles, 
and  an  apex. 

The  anterior  face  is  smooth,  polished,  slightly  convex,  covered  on 
its  superior  two-thirds  by  a  prolongation  of  the  peritoneum,  and  is  in 
contact  with  the  posterior  face  of  the  bladder,  from  which  it  is  some- 
times separated  by  some  folds  of  the  small  intestine ;  inferiorly,  it  is 
united  to  the  bas-fond  of  the  bladder  by  loose  cellular  tissue,  and 
which  adhesion  may  account  for  the  involvement  of  the  bladder  in 
many  uterine  displacements. 

The  posterior  face  is  more  convex  than  the  anterior,  and  is  covered 
throughout  its  whole  extent  by  a  prolongation  of  the  peritoneum ;  it  is 
likewise  in  contact  with  the  anterior  surface  of  the  rectum  looking 
toward  the  concavity  of  the  sacrum.  The  superior  border,  base  or 
fundus,  is  convex,  looking  upward  and  forward,  and  is  covered  in  its 
whole  extent  by  a  prolongation  of  the  peritoneum,  and  by  the  convo- 
lutions of  the  small  intestines.  In  the  unimpregnated  state  it  never 
reaches  the  level  of  the  superior  strait,  and  can  not,  therefore,  be  felt 
through  the  inferior  abdominal  wall,  except  by  making  considerable 
pressure.  The  two  lateral  borders  are  irregular,  being  convex  in  their 
superior  half,  and  concave  in  their  inferior;  they  are  situated  between 
the  two  duplicatures  of  the  peritoneum;  which  constitute  the  broad 
and  round  ligaments,  and  which  ligaments  being  attached  to  the  an- 
terior edge  of  the  lateral  borders,  are  consequently  on  the  same  plane 
as  the  anterior  face  of  the  uterus.  The  two  superior  [grooved]  angles, 
or  cornua  uteri,  are  formed  at  the  junction  of  the  superior  with  the 
two  lateral  borders,  and  from  which  point  arise'  the  Fallopian  tubes 


74  KING'S  ECLECTIC  OBSTETRICS. 

and  ovarian  ligaments;  the  apex  is  the  inferior  extremity  of  the  uterine 
neck,  and  is  situated  in  the  upper  part  of  the  vagina. 

The  CERVIX  UTERI,  or  NECK  OF  THE  UTERUS,  should  be 
thoroughly  studied  by  the  practitioner,  with  regard  to  its  form,  size, 
and  consistence,  in  order  to  facilitate  his  diagnosticating  the  state  of 
pregnancy,  full  term,  etc.,  as  well  as  the  many  abnormal  conditions  to 
which  it  is  liable. 

The  neck  of  the  uterus  in  the  adult  female, who  has  never  borne 
children,  will  be  found  to  vary  considerably  from  that  of  one  who 
has;  it  is  from  twelve  to  fifteen  lines  in  length,  cylindrical,  flattened 
from  before  backward,  and  fusiform;  being  about  nine  lines  in  its 
transverse  diameter  at  the  center,  and  from  four  to  six  lines  at  its  ex- 
tremities. It  is  embraced  by  the  vagina  toward  its  upper  portion, 
leaving  about  two-thirds  within  the  vagina,  and  one-third  above  the 
vaginal  adhesion.  The  inferior  or  vaginal  extremity  of  the  neck,  is 
of  less  volume  than  any  other  part  of  it,  and  is  perforated  in  its  center 
by  a  transverse  fissure  or  orifice,  of  one  or  two  lines  in  length,  to 
which  several  names  have  been  applied,  as,  os  tinea:.,  os  uteri,  os  inter- 
num,  mouth  of  the  womb,  uterine  orifice,  etc.  In  the  virgin, this  orifice 
is  completely  closed  up,  and  is  sometimes  difficult  to  find;  the  sensa- 
tion conveyed  to  the  finger  in  contact  with  it,  is  similar  to  that  expe- 
rienced by  feeling  the  depression  between  the  alse  nasi,  at  the  end  of 
the  nose,  with  the  pulp  of  the  finger,  and  which  sensation  will  assist 
us  in  recognizing  the  opening.  The  os  tinea?  divides  the  apex  into 
two  lips,  an  anterior  and  a  posterior  lip.  These  lips  are  smooth, 
regular,  small,  firm,  thin,  and  closely  approximated;  the  one  anterior 
being  slightly  thicker  and  more  prominent  than  the  posterior.  As 
the  long  diameter  o/  the  uterus  is  nearly  parallel  with  the  diameter 
of  the  superior  strait,  the  face  of  the  apex  will  be  found  looking  to- 
ward the  lower  portion  of  the  sacrum,  in  an  inclined  position;  from 
which  arrangement  the  anterior  lip  will  be  found  a  little  lower  down 
than  the  posterior. 

In  the  woman  who  has  borne  children,  the  uterine  neck  varies  in  its 
extent,  being  reduced  in  length,  according  to  the  number  of  births,  so 
much  so,  that  instances  are  recorded  in  which  the  mothers  of  nineteen 
or  twenty  children  had  the  portion  within  the  vagina  completely  de- 
stroyed; the  orifice  is  usually  deformed,  gaping,  larger,  and  less 
regular,  and  sufficiently  patulous  to  admit  the  introduction  of  the  end 
of  the  finger;  the  lips  are  thicker  and  softer  than  in  the  virgin,  and 
are  filled  with  fissures  or  inequalities,  which  are  more  frequent  on  the 
left  side  of  the  neck,  and  are  the  results  of  lacerations  of  the  fibers- 


INTERNAL    ORGANS    OF    GENERATION. 


75 


which  occur  during  the  passage  of  the  child's  head  through  the  os 
uteri,  and  which  have  been  prevented  from  uniting  by  the  lochial  dis- 
charges. These  fissures  are  of  variable  depth,  and  sometimes  are  so 
numerous  as  to  divide  the  lips  into  eight  or  ten  small  tubercles.  These 
differences  are  of  much  importance  in  legal  medicine ;  yet  they  may 
occasionally  be  produced  by  other  causes  than  parturition,  or  may  even 
be  wanting  in  the  mother. 

The  INTERNAL  SURFACE  of  the  uterus  presents  a  narrow, 
oblong,  irregular  cavity,  with  contiguous  walls,  which  is  divided  into 
two  parts,  the  cavity  of  the  body  and  the  cavity  of  the  neck.  (Fig.  20.) 

The  cavity  of  the  body  is  triangular  in  shape,  flattened,  and  when 
empty  is  not  very  extensive,  being  hardly  large  enough  to  contain  a 
split  almond.  At  each  of  its  three  angles  there  is  an  orifice,  the  knver 
or  inferior  one  leading  to,  and  establishing  a  communication  with,  the 
cavity  of  the  neck,  and  the  two  upper  or  superior  ones  forming  the 
entrance  into  the  Fallopian  tubes;  the  openings  in  these  latter  are 
very  narrow,  and  will  scarcely  admit  a  hog's  bristle.  Occasionally, 
this  opening  is  divided  by  a  perfect  septum,  which  may  render  super- 
fetation  possible,  and  very  rarely  there  exists  a  congenital  deficiency 
of  it.  In  the  absence  of  the  catamenial  discharge  this  cavity  is  con- 
stantly moistened  by  a  sero-mucous  fluid. 

FIG.  20. 


CAVITY  OF  THE  UTERUS,  AND  THE  FALLOPIAN  TUBES. 


A.  Fundus  of  the  Womb. 

B.  Cavity  of  the  Womb. 

C.  Cavity  of  the  Neck  of  the  Womb. 

D  D.  The  Canal  of  the  Fallopian  Tubes 

laid  open. 
E  E.  The  fimbriated  Extremities. 


F  F.  The  Ovaries.     . 
G  G.  The  round  Ligaments. 
H  H.  The  Ligaments  of  the  Ovaries. 
I.  The  Cavity  of  the  Vagina. 
6,  H'.  The    Uterine   Orifices  of  the  Fallopian 
Tubes. 


The  canal,  or  cavity  of  the  neck,  affords  a  communication  between  the 
cavity  of  the  body  and  the  vagina;  it  is  oval  and  cylindrical,  about 
twelve  or  fifteen  lines  in  length,  and  five  or  six  in  its  greatest  breadth; 
it  is  fusiform,  flattened  from  before  backward,  presenting  on  its 


76  KINfi's     KCLKCTIC    OIJSTKTKICS. 

anterior  and  posterior  wall  several  longitudinal  and  transverse  rugae  or 
wrinkles,  to  which  the  terms  arbor  rifn  mternus,  palmce  pUcatce,  &nd 
/icnnifonit  r  u  gee,  have  been  applied;  they  are  formed  by  the  lining 
membrane  of  the  neck,  and  which  are  so  arranged  as  to  represent  a 
fern  leaf  in  relief;  they  extend  during  the  dilatation  of  the  mucous 
membrane  of  the  cervix  in  the  uterine  development  from  gestation, 
an<!  during  parturition,  and  frequently  disappear  after  delivery.  On 
the  mucous  membrane  of  the  neck  are  a  number  of  muciparous  fol- 
licles, more  abundant  about  the  os  uteri,  which  were  mistaken  by 
Naboth  for  eggs,  and  hence  have  been  called  ovula  Nabothi,  glandula 
Nabothi,  or  the  glands  of  Naboth.  In  the  healthy  uterus  of  the  virgin, 
these  follicles  can  hardly  be  seen;  but  during  pregnancy,  or  when  dis- 
ease attacks  the  parts,  they  enlarge  so  as  to  be  readily  recognized  by 
the  eye,  and  when  touched  with  the  finger  they  feel  like  shot.  During 
pregnancy,  they  secrete  a  thick,  tough,  pellucid,  gelatinous  mucus,  in 
quantity  sufficient  to  close  up  the  cavity,  and, thus  prevent  any  com- 
munication between  the  cavity  of  the  body  and  the  vagina.  The  in- 
ternal surface  of  the  neck  is  less  vascular  than  in  the  body.  '  Ciliated 
cylinder  epithelium  is  observed  upon  the  mucous  membrane  of  the 
canal  of  the  cervix,  but,  at  its  lower  part,  instead  of  cylinder  there  is 
squamous  epithelium  resembling  that  of  the  vagina,  and  beneath  which 
are  found  verrucose  or  filiform  papillae,  containing  one  or  two  vascular 
loops;  those  seated  more  directly  in  the  neighborhood  of  the  os  uteri 
apparently  possess  a  peculiar  sexual  sensitiveness. 

The  character  of  the  uterine  tissue  is  very  difficult  to  understand 
in  its  unimpregnated  condition,  but  becomes  more  manifest  during 
gestation.  Its  constituent  parts  are:  an  external  peritoneal  membrane, 
an  internal  or  mucous  membrane,  a  peculiar  tissue,  and  numerous 
blood-vessels  and  nerves. 

The  external  peritoneal  membrane  is  furnished  by  the  peritoneum, 
which,  after  having  covered  the  posterior  surface  of  the  bladder,  is 
reflected  from  behind  forward,  upon  the  anterior  face  of  the  uterus, 
covering  its  superior  three-fourths,  and  extending  over  the  fundus 
uteri  and  posterior  surface  of  the  uterus;  it  is  then  prolonged  on  the 
vagina  for  a  short  distance,  and  from  thence  reflected  upon  the  rectum. 
In  front  of,  and  behind  the  uterus,  this  membrane  forms  four  small 
falciform  folds;  those  which  are  in  the  space  between  the  bladder  and 
uterus  are  named  the  vesico-uterine,  or  anterior  ligaments;  and  those 
situated  between  the  rectum  and  uterus,  being  termed  the  recto-uteri  in , 
or  posterior  ligaments.  On  the  borders  of  the  uterus  the  attachments 


INTERNAL    OUOJANS    OF   GENERATION.  77 

of  the  peritoneum  are  quite  loose,  but  become  more  intimate  toward 
the  median  line. 

The  existence  of  the  internal,  or  mucous  membrane,  has  been  very 
much  doubted  by  many  anatomists,  as  may  be  seen  from  the  following 
observations  by  Moreau :  ' 

"On  examination,  we  find  the  inner  surface  of  the  body  of  the 
uterus  to  be  soft,  pulpy,  having  neither  the  brilliancy  of  the  peri- 
toneum, nor  the  whiteness  of  the  mucous  membrane  of  the  vagina; 
of  a  reddish  or  blackish  brown  color;  it  generally  contains,  whatever 
may  have  been  the  circumstances  preceding  the  death  of  the  woman, 
a  brown  or  dirty  gray  fluid.  When  the  uterus  is  macerated,  or  boiled, 
or  dissected  soon  after  death,  it  is  impossible  to  trace  the  mucous 
membrane  beyond  the  cavity  of  the  neck.  If,  on  the  other  hand,  we 
observe  that  all  the  hollow  organs  provided  with  mucous  membranes, 
such  as  the  stomach,  intestines,  bladder,  and  the  vagina  itself,  and  which 
are  required,  by  their,  functions,  to  change  in  size,  present,  when 
empty,  a  rugose  surface  and  folds  more  or  less  projecting,  formed  by 
the  lining  membrane;  that  this  membrane  is  furnished,  moreover, 
with  numerous  follicles,  which  pour  out  mucus  intended  to  protect  the 
organ  from  the  irritation  of  the  substances  or  bodies  they  may  contain, 
or  which  may  pass  through  them,  we  will  see  that  no  similar  arrange- 
ment obtains  in  the  cavity  of  the  body  of  the  uterus;  the  follicles  are 
found  only  in  the  cavity  of  the  neck;  they  are  there  disposed  symmet- 
rically, on  four  opposite  lines,  two  on  the  anterior  and  two  on  the 
posterior  paries.  If  the  uterus  were  provided  with  a  mucous  mem- 
brane, could  it  bear  the  enormous  enlargement  resulting  from  preg- 
nancy, without  lacerations  of  its  internal  surface,  such  as  frequently 
occur  in  the  vagina  at  the  time  of  delivery,  and  of  which  traces 
may  be  seen  almost  always  in  women  who  have  borne  children? 
Moreover,  in  advanced  age,  we  often  find  obliteration  of  the  cayity  of 
the  body  of  the  uterus,  as  well  as  of  the  tubes.  We  have  long 
observed  this  fact,  which  is  confirmed  by  the  researches  of  Mayer, 
reported  by  Breschet,  and  what  is  very  remarkable,  this  obliteration, 
the  natural  consequence  of  age,  does  not  extend  beyond  the  internal 
orifice,  at  the  point  at  which  we  have  said  the  mucous  membrane 
terminates.  In  organs  lined  by  a  true  mucous  membrane,  the  cavity 
always  remains.  In  old  cases  of  artificial  anus,  that  part  of  the  intes- 
tinal canal  below  the  accidental  opening,  no  longer  giving  issue  to 
fecal  matter,  contracts,  but  never  consolidates. 

"  We  shall  terminate  these  considerations  by  a  single  remark.  The 
serous  and  mucous  tissues,  evidently  communicate  by  means  of  the 


78  KIND'S    ECLECTIC    OI5STETUICS. 

aperture  of  the  Fallopian  tubes.  Is  there  a  point  at  which  these 
ti>.-ui's  change,  and  are  transformed  into  each  other?  Undoubtedly 
there  is;  l>ut  \\here  is  it?  Is  the  serous  tissue  suddenly  arrested  at 
the  dictations  of  the  tubes?  Does  it  line  the  cavity  of  the  fimbiiated 
extremity?  Does' it  extend  along  the  tube  as  far  as  the  uterus?  Or 
does  the  mucous  tissue  occupy  the  whole  cavity  ?  Is  the  latter  pro- 
longed, as  it  is  said,  into  the  cavity  of  the  tube?  Does  it  terminate 
;tt  the  fimbriated  extremity,  or  extend  beyond?  This  can  not  be 
demonstrated.  If  it  be  impossible  to  assign  the  precise  point  at 
which  one  of  these  tissues  commences,  and  the  other  ends,  is  it  not 
reasonable  to  regard  the  cavity  of  the  body  of  the  uterus,  and  of  the 
Fallopian  tubes,  as  respiratory  surfaces,  intermediate  by  their  position, 
organization,  and  uses,  to  the  serous  and  mucous  tissues;  upon  them 
the  transformation  is  exerted,  but  in  a  gradual,  successive  manner, 
without  being  able  to  determine  accurately  the  point  of  mutation. 

"  This  opinion  acquires  more  value  if  we  observe  that  the  exhala- 
tions of  the  internal  surface  of  the  uterus  are  not  identical  over  its 
whole  extent.  Haller  had  already  found  in  the  cavity  of  the  body, 
a  serous,  whitish,  muddy,  and  thin  liquid,  which,  in  the  uterus  of 
a  newly  born  child,  resembled  milk,  while  that  in  the  cavity  of  the 
neck  was  a  thick,  dense,  and  reddish  mucus.  The  exhalations  of  the 
cavity  of  the  body  of  the  uterus,  present  under  various  circumstances, 
but  normal  for  them,  the  characters  of  exhalation  of  the  mucous 
and  serous  tissues,  alternately  morbid  and  physiological.  Thus,  in 
ordinary  health,  the  matter  exhaled  by  the  uterine  cavity,  has  a  great 
analogy  with  mucus.  When  this  surface  is  excited  in  a  special  manner 
by  the  act  of  generation,  the  fluid  produced  resembles  more  the  serous 
exhalations;  it  is  a  concrescible,  plastic  lymph,  which  becomes  con- 
densed, and  quickly  changed  into  a  species  of  false  membrane,  the 
caducci*  When  simply  the  seat  of  some  fluxive  function,  as  at  the 
menstrual  periods,  a  phenomenon  is  manifested  which  belongs  equally 
to  overexcited  or  highly  inflamed  mucous  and  serous  tissues,  a  san- 
guine discharge  is.  established,  the  affluxus  is  dispelled,  and  nature 
resumes  her  usual  course. 

"  We  may  hence  conclude,  that  the  cavity  of  the  body  of  the  uterus 
possesses  no  mucous  membrane ;  or  if  it  exists,  it  has  undergone  such 
modifications  as  to  leave  no  longer  any  resemblance  to  the  same  tissue 
in  other  parts." 

Cazeaux,  likewise,  observes  in  relation  to  this  membrane :  "  To  the 
reasons  already  offered  by  Morgagni,  Chaussier,  etc.,  in  favor  of  its 
existence,  we  shall  add  those  presented  by  Cruveilhier,  which  appear 


INTERNAL   ORGANS    OF    GENERATION'.  79 

to  us  perfectly  conclusive,  viz.:  1st.  Every  organic  cavity  communi- 
cating with  the  exterior  is  lined  by  a  mucous  membrane.  2d.  Anatomy 
demonstrates  that  the  vaginal  mucous  membrane  is  continued  into  the 
cavity  of  the  neck,  and  then  into  that  of  the  uterus,  only  it  is  deprived 
of  its  epithelium  in  penetrating  the  latter.  3d.  When  examined  by  a 
lens,  the  internal  surface  of  the  uterus  exhibits  a  papillary  disposition, 
but  the  papillae  are  imperfectly  developed.  4th.  This  internal  surface 
has  follicles  or  crypts  spread  over  it,  from  which  mucous  can  b<j 
squeezed  out,  and  which,  if  their  orifices  be  obstructed  or  obliterated, 
become  distended  by  the  liquid,  and  form  little  vesicles.  5th.  It  is 
continually  lubricated  by  mucus.  6th,  and  lastly;  the  internal  surface 
of  the  uterus,  like  all  other  mucous  membranes,  is  subject  to  sponta- 
neous hemorrhages,  to  catarrhal  secretions,  and  to  the  mucous,  fibrous, 
and  vesicular  vegetations,  called  polypi;  and  it  is  generally  admitted 
that,  wherever  there  is  an  identity  of  action,  there  is  also  an  identity 
of  nature."  • 

That  the  inner  membrane  of  the  uterine  walls  is  composed  of  a  mu- 
cous body  or  tissue,  has,  according  to  the  recent  microscopic  observa- 
tions of  M.  Coste,  and  others,  been  decided  in  the  affirmative,  and 
which  is  probably  continuous  with  the  lining  mucous  membrane  of  the 
vagina,  and  of  the  Fallopian  tubes,  but  which  has  no  submucous  tis- 
sue, being  closely  attached  to  the  muscular  coat.  It  consists  of  tubular 
utricular  follicles  or  glands,  arranged  perpendicularly  with  the  surface, 
simple  or  bifurcated,  spirally  contorted  at  the  end,  from  one  thirty- 
third  to  one  fiftieth  of  a  line  in  diameter,  their  length  being  that  of 
the  thickness  of  the  mucous  membrane,  and  consisting  of  very  deli- 
cate membrane  and  ciliated  cylindrical  epithelium  ;  the  cilia  vibrating 
from  below  upwards,  and  thus  very  likely  aiding  in  conveying  the 
spermatic  filaments  to  the  Fallopian  orifices.  The  secretion  from  these 
glands  probably  forms  the  decidua. 

The  peculiar  tissue  of  the  uterus,  which  is  under  the  mucous  mem- 
brane, and  is  named  the  middle,  fleshy,  or  muscular  coat  of  the  uterus ; 
is  very  dense  in  structure,  resisting,  of  a  dirty  grayish  color,  being 
sometimes  slightly  pearly  near  the  neck,  crackles  like  cartilage  under 
an  incision  with  the  scalpel,  and  constitutes  the  greater  part,  if  not  the 
fundamental  structure  of  the  organ.  In  the  unimpregnated  state  of 
the  uterus,  it  is  very  difficult  to  determine  the  true  character  of  the 
uterine  tissue,  as  it  varies  in  color  and  density,  its  fibrous  organizations 
being  concealed  by  the  state  of  condensation  of  the  organ.  There  has 
been  considerable  difference  of  opinion  upon  this  point,  some  viewing 
it  as  belonging  to  the  fibrous  tissue,  and  others  to  the  muscular ;  the 


80  KIXCi'K    ECLECTIC    015STETRICS. 

condition  of  pregnancy,  however,  removes  all  doubt  and  uncertainty, 
and  presents  to  us  a  true  muscular  tissue. 

The  arteries  of  the  uterus  come  from  the  hypogastrics,  or  internal 
iliacs,  under  the  name  of  uterine  arteries,  and  from  the  aorta,  or  renal 
arteries,  under  the  name  of  ovarian  or  spermatic  arteries.  The  uterine 
arteries  penetrate  the  uterus  by  its  lateral  borders,  and  describe  a  num- 
ber of  flexuosities  in  the  proper  tissue  of  the  organ ;  the  branches  of 
the  same  side  frequently  anastomose  with  each  other,  and  unite  on  the 
median  line  with  those  of  the  opposite  side.  They  likewise  commu- 
nicate above  and  laterally  with  the  branches  of  the  ovarian  arteries, 
and  terminate  in  the  interior  tissue,  continuing  into  the  veins,  and, 
probably,  presenting  orifices  within  the  uterine  cavity. 

The  veins  follow  the  course  of  their  respective  arteries ;  they  are 
very  numerous,  have  no  valves,  and  empty  into  the  corresponding 
trunks :  the  right  spermatic  into  the  inferior  cava,  the  left  into  the 
renal  vein,  and  the  uterine  veins  into  the  internal  iliacs.  The  arrange- 
ment of  the  veins,  in  the  uterine  tissue,  is  analogous  to  that  observed 
in  the  corpora  cavernosa,  and  the  erectile  tissues ;  and  their  orifices  on 
the  internal  surface  of  the  uterus,  are  very  large  during  pregnancy, 
and  become  visible  just  after  delivery. 

The  nerves  are  derived,  one  portion,  from  the  sacral  plexus  of  the 
cerebro-spinal  system,  which  more  especially  supplies  the  cervix  with 
nervous  filaments,  and,  consequently,  renders  it  more  sensitive  to  the 
touch  than  any  other  part  of  the  organ ;  the  other  portion,  being  des- 
tined to  the  organic  life  alone,  is  from  the  great  sympathetic  nerve, 
which  supplies  the  body  of  the  organ  with  filaments,  and  which  will 
explain  to  us  how  most  of  the  vital  organs  of  the  body,  especially  the 
brain  and  stomach,  sympathize  so  readily  with  the  uterus,  both  in  dis- 
ease and  during  pregnancy.  The  performance  of  the  several  functions 
of  menstruation,  conception,  and  parturition,  is,  without  doubt,  chiefly 
owing  to  the  influence  of  the  uterine  nerves. 

The  lymphatic  vessels  are  very  numerous,  and  arise  from  different 
parts  of  the  organ,  forming  reticulations,  branches,  and  trunks,  which, 
united  in  bundles,  leave  the  uterus  in  three  different  directions.  The 
least  numerous  leave  the  abdomen  by  the  inguinal  canal,  and  are 
distributed  to  the  inguinal  ganglia;  others,  united  to  the  lymphatics 
of  the  vagina,  accompany  the  uterine  and  vaginal  arteries,  and  ter- 
minate in  the  hypogastric  lymphatic  plexus.  But  the  most  numerous 
arise  from  the  anterior  and  posterior  surfaces  of  the  neck  and  of  the 
body,  run  toward  the  lateral  borders,  follow  their  direction,  are  then 
united  with  those  of  the  ovaria,  the  tubes,  and  fundus  uteri,  ascend 


THE   UTERINE   APPENDAGES.  81 

the  ovarian  arteries  and  veins,  in  front  of  the  psoas  muscle,  to 
join  the  ganglia  situated  in  front  of  the  aorta,  the  vena  cava,  and  in 
the  vicinity  -of  the  kidneys. 

All  the  above  vessels,  etc.,  are  very  small  during  the  condensed  or 
unimpregnated  condition  of  the  uterus,  but  increase  in  size  during 
pregnancy,  and  at  full  term  acquire  an  enormous  size,  supplying  the 
organ  with  torrents  of  blood.  The  lymphatic  vessels,  also,  play  a  very 
important  par,t  in  the  diseases  of  the  uterus. 

Sometimes  the  uterus  is  absent  entirely,  at  others  but  slightly  devel- 
oped, or  it  mayjbe  malformed,  or  in  an  abnormal  position.  It  is  liable 
to  hernia,  prolapsus,  retroversioii,  anteversion,  inversion,  ulcerations, 
inflammations,  etc.,  the  history  and  treatment  of  which  may  be  found 
in  any  treatise  on  the  diseases  of  women. 


CHAPTER    X. 

OF  THE    UTERINE   APPENDAGES THE    LIGAMENTS,  THE   FALLOPIAN 

TUBES,  AND    THE    OVARIES. 

THE  uterus  is  supported,  in  the  pelvic  cavity,  by  six  duplicatures  of 
peritoneum — two  anterior,  or  vesico-uterine,  and  two  posterior,  or  recto- 
uterine  ligaments,  to  which  reference  has  been  heretofore  made ;  also 
two  lateral,  or  broad  ligaments,  which  are  much  larger  and  more  im- 
portant than  the  others,  as  within  them  we  find  contained  the  round 
ligaments,  the  Fallopian  tubes,  and  the  ovaries  (Fig.  19). 

The  BROAD  LIGAMENTS  are  formed  by  two  duplicatures  of 
the  peritoneum,  which,  covering  the  anterior  and  posterior  faces  of  the 
uterus,  are  prolonged  transversely,  extending  to  the  ilia;  these  two 
folds  rest  against  each  other,  and  divide  the  pelvis  into  two  cavities — 
the  anterior  cavity  containing  the  bladder,  and  the  posterior  the  rec- 
tum. These  ligaments  are  of  a  quadrilateral  shape,  and  from  their 
supposed  resemblance  to  the  wings  of  a  bat  extended,  have  been 
named  the  alee  vespertilionis.  Outwardly,  and  below,  these  ligaments 
are  continuous  with  the  peritoneum  that  lines  the  excavation;  their 
upper,  or  superior  border  is  loose,  and  extends  from  the  angles  of  the 
uterus  to  the  iliac  fossse,  presenting  three  small  folds,  called  a/ce,,<or 
wings.  The  anterior  wing  is  not  distinctly  developed,  and  is  denied 
by  some  anatomists ;  it  is  occupied  by  the  round  ligament.  The.  mid-* 


82  KING'S  ECLECTIC  OBSTETRICS. 

die  wing  incloses  the  Fallopian  tube,  and  the  posterior  contains  the 
ovary  and  its  ligament. 

The  space  between  the  two  serous  folds, constituting  the  broad  liga- 
ment, is  filled  by  a  loose  and  very  extensible  lamellated  cellular  tissue, 
continuous  with  the  fascia  propria  of  the  pelvis,  and  which  is  traversed 
by  the  uterine  vessels  and  nerves.  As  gestation  advances,  and  the 
uterus  enlarges,  the  two  laminaB  of  the  peritoneum  separate  to  receive 
the  uterus,  assisting  to  cover  its  anterior  and  posterior  surfaces,  and  in 
consequence,  during  the  latter  month  of  pregnancy,  the  broad  liga- 
ments entirely  disappear. 

The  ROUND  LIGAMENTS,  or  supra-pubic  cords,  are  two  in 
number,  one  on  each  side ;  they  are  of  cylindrical  form,  six  or  seven 
inches  in  length,  of  a  fibrous  appearance,  and  of  a  grayish  white  color. 
They  arise  from  the  lateral  borders  of  the  uterus,  below  and  a  little  in 
advance  of  the  Fallopian  tube,  and  are  directed  upward  and  outward, 
following  the  direction  of  the  pelvis  ;  they  are  enveloped  in  a  cellular 
tissue,  and  are  covered  by  a  prolongation  of  the  peritoneum,  to  which 
the  name  "  Canal  of  Nuck,"  has  been  given.  They  enter  the  inguinal 
canal  on  each  side,  traverse  it,  emerge  by  the  corresponding  inguinal 
ring,  and  divide  in  front  of  and  above  the  pubes  into  a  number  of 
fibrous  fasciculi,  which  are  lost  in  the  cellular  tissue  of  the  groins, 
mons  veneris,  and  labia  pudendi.  They  contain  a  great  number  of 
veins,  which  are  liable  to  become  varicose. 

There  has  been  considerable  controversy  as  to  the  structure  of  these 
ligaments,  but  the  investigations  of  modern  anatomists  have  ascer- 
tained them  to  be  expansions  or  prolongations  of  the  muscular  fibers 
of  the  uterus,  containing  blood-vessels,  nerves,  lymphatics,  and  cellular 
tissue. 

The  real  uses  of  the  round  ligaments  are  not  satisfactorily  known ; 
they  are  supposed  to  be,  to  retain  the  uterus  in  its  proper  position,  and 
to  prevent  its  displacements.  During  pregnancy,  chronic  affections, 
or  uterine  displacements,  these  ligaments  are  subject  to  inflammation 
and  engorgement,  and  which  conditions  may,  probably,  be  the  cause 
of  the  pains  in  the  groins,  frequently  experienced  by  women  thus 
circumstanced. 

The  FALLOPIAN,  or  UTERINE  TUBES,  (oviducts,  vector  ca- 
nals), are  two  cylindrical  canals,  from  four  to  five  inches  in  length, 
of  a  conical  shape,  flexuous  and  waving,  and  extend  from  the  upper 
or  superior  angles  of  the  uterus  to  the  ovaries;  they  are  placed  in  the 


THE    UTERINE    APPENDAGES.  83 

thickness  of  the  middle  wing  of  the  broad  ligaments.  The  internal 
cavity  of  these  tubes  is  very  narrow  at  their  uterine  extremities,  but, 
as  they  extend  outwardly,  i|  gradually  increases  in  size,  but  again  con- 
tracts just  before  opening  at  the  fimbriated  extremity.  The  internal 
extremities  of  the  tubes  are  inserted  into  the  superior  angles  of  the 
uterus,  where  they  open  into  the  cavity  of  its  body,  their  orifices 
being  named  the  internal  or  uterine.  The  external  or  free  extremities 
of  the  tubes,  called  the  fimbriated  extremities  or  pavilion,  communicate 
with  the  peritoneal  cavity  by  an  oblong,  inverted  opening,  with  digi- 
tated or  fringed  edges,  of  which  one  is  longer  than  the  other,  curved, 
and  inserted  into  the  external  extremity  of  the  ovary ;  the  other  hangs 
loosely  over  the  ovarium.  The  openings  at  these  ends  .of  the  tubes 
are  named  the  free  orifices  of  the  tubes;  the  orifice  at  either  uterine 
angle  is  called  the  ostium  uterinum,  that  at  either  fimbriated  extremity, 
the  ostium  abdominale. 

The  tubes  are  enveloped  by  the  peritoneum,  which  forms  the  outer 
or  external  tunic  or  membrane ;  the  internal  membrane  is  a  prolonga- 
tion of  the  uterine  mucous  membrane  (which,  however,  is  denied  by 
some  authors),  and  is  also  continuous  with  the  serous  peritoneum;  the 
tubes  are  composed  of  two  laminae  of  unstriped  muscular  fibers,  the 
exterior  of  which  have  a  longitudinal  direction,  while  the  internal  are 
circular.  Their  vessels  are  derived  from  the  ovarian  arteries,  and  their 
nerves  from  the  great  sympathetic.  The  middle  layer  or  proper  tissue 
of  the  tubes,  is  a  continuation  of,  and  identical  in  texture  with,  that 
of  the  uterus.  The  internal  lining  mucous  membrane  of  the  Fallopian 
tubes  is  thin,  in  longitudinal  folds  permitting  dilatation,  and  is  covered 
by  ciliated  cylindrical  epithelium,  the  movements  of  which  are  directed 
from  the  ostium  abdominale  to  the  ostium  uterinum. 

The  Fallopian  tubes  serve  to  conduct  the  fecundating  principle  of 
the  male  to  the  ovaries,  and  to  seize  the  impregnated  germ  or  ovule 
of  the  female  and  transmit  it  to  the  uterus.  At  the  moment  of  fecunda- 
tion, the  fimbriated  extremity  grasps  the  escaping  ovum  (morsus  dia- 
boli),  and  probably  also  at  each  menstrual  period;  a  failure  of  this 
action,  or  of  the  peculiar  offices  of  the  tubes,  may,  probably,  be  a 
cause  of  extra-uterine  pregnancy. 

The  OVARIES  furnish  the  ovula  which  contain  the  rudiments  of  the 
future  animals ;  they  are  situated  in  the  thickness  of  the  posterior  wing 
of  the  broad  ligaments,  behind  and  below  the  Fallopian  tubes ;  they 
are  two  in  number,  oblong,  oval,  whitish,  twelve  or  fifteen  lines  long, 
and  flattened  from  before  backward,  being  about  the  size  and  shape  of 


84  KING'S  ECLECTIC  OBSTETRICS. 

an  almond.  Previous  to  puberty,  and  sometimes  in  virgins  and  women 
who  have  not  borne  children,  their  surface  is  polished  and  embossed; 
but  after  puberty,  owing  to  the  escape  of  ^he  ova,  they  become  rough 
and  fissured.  Their  superior  border  is  convex  and  loose ;  their  in- 
ferior, straight,  or  slightly  concave,  and  adhering  to  the  broad  liga- 
ments, by  which  they  are  maintained  in  position,  as  also  by  a  special 
one,  named  the  ligament  of  the  ovary  (ligamentum  ovarii),  a  dense, 
imperforate  cellule-fibrous  cord,  which  fixes  the  internal  ovarian  ex- 
tremities to  the  uterus.  The  external  extremities  are  joined  to,  or  ap- 
proximate, the  fimbriated  Fallopian  extremities.  The  nerves  of  the 
ovaries  come  from  the  renal  plexus,  and  the  blood-vessels  which  are 
called  the  ovarian,  have  a  similar  origin  with  the  spermatic  vessels  in 
the  male.  The  situation  of  the  ovaries  varies  according  to  circum- 
stances; in  the  fetus  they  are  in  the  lumbar  region;  during  gestation 
they  rise  into  the  abdomen  along  with  the  body  of  the  uterus,  upon 
the  sides  of  which  they  are  attached;  and  immediately  after  delivery, 
they  occupy  the  iliac  fossae,  where  they  sometimes  continue  through 
life.  It  is  not  uncommon  to  find  them  pIG  2i. 

turned  backward,  and  adhering  to  the 
posterior  uterine  surface.  They  like- 
wise vary  in  size,  being  larger  in  pro- 
portion in  the  fetus  than  at  maturity, 
decreasing  after  birth,  enlarging  at  pu- 
berty and  during  pregnancy,  and  dwind- 
ling away  as  old  age  approaches;  they 

frequently  become   the   seat   of  organic 

*  EXTERNAL  FACE  OF  THE  OVARY 

alterations.     (Fig.  21.) 

The  external  covering  of  the  ovaries  is  obtained  from  the  peri- 
toneum, and  is  named  -the  indusium.  Beneath  this  covering,  the  body 
of  each  ovary  is  invested  with  a  whitish,  dense,  fibrous  membrane, 
called  the  tunica  albuginea,  which  is  the  proper  tunic  of  these  organs, 
and-  which  may  be  considered  as  an  expansion,  or  extension  of  the 
ovarian  ligaments.  From  the  internal  surface  of  this  membrane 
proceed  prolongations  which  divide  the  ovaries  into  many  small  cells 
filled  by  their  proper  tissue.  The  parenchyma  of  the  ovaries,  or  tissue 
proper,  is  of  a  reddish  brown  color,  spongy,  dense,  and  vascular, 
bearing  some  resemblance  to  the  erectile  tissue,  it  is  called  the  stroma; 
in  this  tissue  are  found  imbedded  a  number  of  small  transparent  folli- 
cles or  vesicles,  varying  in  size  from  the  smallest  pin's  head  to  that 
of  a  large  shot,  the  smaller  being  within — the  larger  and  better  de- 
veloped more  toward  the  surface.  These  last  sometimes  produce  small 


THE    UTERINE   APPENDAGES. 


85 


FIG.  22. 


elevations  on  the  stroma,  which  give  a  rough  or  tuberculous  appear- 
ance to  the  whole  ovary;  they  are  called  the  ovisacs,  or  Graafian  vesicles, 
after  De  Graaf,  who  gave  a,, description  of  them. 

The  Graafian  vesicles  number  from  fifteen  to  twenty  in  the  adult 
female,  in,  or  near  a  state  of  maturity,  but  with  the  aid  of  a  microscope 
many  more  can  be  seen  which  gradually  become  developed  as  the  others 
perfect  their  function.  They  are  hardly  visible  in  children  and  old  wo- 
men, but  are  very  distinct  during  the  menstrual  life.  (Fig.  22.)  Each 
ovary  at  birth  contains  not  less  than  thirty- five  thousand  ova.  (Foulis.) 

The  vesiculaB  Graafianse,  consist 
of  two  separate  tunics ;  1.  The  ex- 
ternal tunic  or  tegument,  which  is  firm, 
fibrous,  and  vascular  in  its  character, 
like  the  stroma  or  proper  ovarian 
tissue ;  2.  The  internal  tunic,  formed 
of  dense  cellular  tissue,  but  thin, 
smooth,  delicate,  diaphanous,  and 
easily  torn ;  some  consider  it  desti- 
tute of  vascularity,  which  is,  again, 
denied  by  others.  From  the  close 
approximation  of  these  two  tunics,  it 
is  sometimes  difficult  to  separate  them. 

The  internal  face  or  cavity  of  the  A.  The  Ovule  abou7i-i7a  line  in  diameter. 

inner  tunic  Contains  the  nucleus,  COm-    G'-  The  Granular  Cumulus,  or  ProligerousDisk. 

K.  The  Cavity  of  the  Graafian  Vesicle. 

prising:  1.   Ihe  granular  membrane,  M.  The  MUCOUS  surface, 
which  is  a  delicate  membrane  formed  v-  The  vascular  Layer. 

F.   The  Fibrous  Layer. 

oi  granules  or  cellules.  I  his  mem-  p.  The  Peritoneal  Coat, 
brane  is  exceedingly  thin  and  very  G"  The  Granular  Membrane, 
easily  torn ;  its  thickest  portion  corresponds  with  the  free  side  of  the 
vesicle,  or  that  portion  which  is  nearest  the  surface  of  the  albuginea, 
and  here  the  granulations  are  more  numerous,  constituting  the  cumulus 
proligerus,  or  discus  proligerus.  2.  A  fluid  either  limpid,  reddish,  or 
slightly  lemon-colored,  concrescible,  and  composed  principally  of  albu- 
men, as  it  is  coagulated  by  heat,  alcohol,  and  the  strong  acids.  In 
this  liquid  float,  vitellary  corpuscle,  oil  globules,  and  a  great  number  of 
small  grains,  which  settle  themselves,  touching  each  other,  upon  the 
inner  wall  of  the  vesicle,  and  form  the  above  named  granular  mem- 
brane. 3.  The  ovule  or  human  egg,  which  is  found  in  the  center  of  the 
proligerous  disk.  (A,  Fig.  22.) 

The  OVULE,  or  HUMAN  EGG  was  first  discovered  as  a  distinct 
organ  in  the  Graafian  vesicle  by  Charles  Ernest  Baer,  though  DeGraaf 
had  suggested  the  idea  previously.  It  is  imbedded,  as  stated  above, 


THE 


OVULE    IN    THE 
VESICLE. 


GRAAFIAN 


86 


KINGS    ECLECTIC    OBSTETi: !«  -. 


A  NON-FECUN'DATED  OVULE  OB 
HUMAN  EGG. 


Pur  kin  je,  about  1-60  of  a  line  in 
diameter. 

D.  The  Germinal  Spot,  from  the  1-400  to 
the  1-600  of  a  line  in  diameter. 


FIG.  23.  in  the  midst  of  the  proligerous  disk,  and 

is  perfectly  formed  in  the  ovary  during 
the  earlier  years  of  life.  It  is  extremely 
minute  and  hardly  to  be  seen  by  the 
naked  eye,  but  when  examined  with  the 
microscope,  presents  an  opaque,  rounded 
appearance.  Bischoff  says :  "  The  largest 
human  ovules  I  have  seen  and  manipu- 
lated, did  not  exceed  the  tenth  of  a  line, 
being  barely  perceptible  to  the  naked 
eye."  As  seen  by  the  microscope,  the 
ovule  is  possessed  of  an  exterior  covering 
called  the  vitelline  membrane,  transparent 
zone,  cortical  membrane,  or  chorion;  of  a 

A.  The   Vitelline   Membrane,  or  Trans- 

parent zone.  substance  denominated  the  yelk  or  vitellus, 

B.  The  Vitellus,  or  Yelk.  3       t  •    i          '.i/u'      Ai  n 

&  The  Germinal  Vesicle,  or  Vesicle  of    and    °f  a  Vesicle  Within  the  yelk,  termed 

the  germinal  vesicle. 

The  Zona  Pellucida,  or  vitelline  mem- 
brane, is  an  elastic,  thick,  hyaline,  and 
transparent  membrane,  without  a  determinate  texture,  whose  external 
and  internal  outlines  assume  the  appearance  of  two  circular  lines 
inclosing  a  transparent  ring.  (A,  Fig.  23.) 

The  yelk  or  vitellus  of  the  human  ovum  occupies  the  cavity  of  the 
vitelline  membrane;  it  is  formed  according  to  Bischoff,  of  a  coherent 
indistinctly  granular,  yellowish,  transparent,  and  viscous  mass,  which 
does  not  run  out  when  the  egg  is  cut  or  crushed;  each  portion  of  the 
zone  reserving  its  particular  segment  of  yelk,  or  the  latter  escaping 
altogether.  It  usually  fills  the  interior  of  the  viteliine  sphere  com- 
pletely, though  it  is  sometimes  smaller,  and  its  granulations  are 
placed  in  juxtaposition  with  its  sole  envelope,  the  transparent  zone. 
(B,  Fig.  23.} 

Within  the  yelk,  or  on  one  of  the  points  of  its  circumference,  is 
discovered  a  slightly  oval,  colorless,  and  perfectly  transparent  vesicle, 
consisting  of  a  very  delicate  membrane,  which  incloses  a  clear  and 
transparent  liquid,  but  which  occasionally  contains  a  few  granulations. 
This  colorless  vesicle  scarcely  measures  the  sixtieth  of  a  line  in  diame- 
ter, is  surrounded  by  a  mass  of  deep  yellow,  and  is  identical  in 
character  with  that  found  in  the  unfecundated  eggs  of  birds.  Fecun- 
dation destroys  it.  This  is  called  the  germinal  vesicle  or  the  vesicle  of 
Purkinje  (c,  Fig.  23).  The  honor  of  its  discovery  is  variously  attrib- 


THE    UTERINE    APPENDAGES.  87 

uted  to  Purkinje,  Baer,  and  Coste,  though  the  latter  is  more  justly 
entitled  to  it. 

If,  according  to  Wagner,  the  germinal  vesicle  be  attentively  exam- 
ined with  the  lens,  at  four  or  five  hundred  diameters,  there  will  be 
seen  on  some  part  of  its  periphery,  a  small,  dark,  round  spot,  which 
consists  of  a  collection  or  stratum  of  fine,  small  lenticular  granules  or 
globules,  and  which  stratum  appears  to  be  the  true  living  .animal 
germ,  existing  previously  to  impregnation.  This  is  called  the  germinal 
spot,  and  was  cotemporarieously  discovered  and  described  by  Professor 
Rudolph  Wagner,  of  Germany,  and  T.  Wharton  Jones,  of  England. 
Two,  or  more  germinal  spots  have  been  met  with  in  the  mammiferse. 
(D,  Fig.  23). 

The  ovule,  therefore,  previous  to  impregnation,  is  composed:  1,  of 
an  exterior  tunic,  the  zona pellucida  or  vitelline  membrane,  within  which 
is  contained,  2,  a  yelk,  which  again  incloses,  3,  a  vesicle,  the  germinal 
vesicle,  within  which  we  find,  4,  a  dark  spot,  the  germinal  spot  or  germ 
from  which  it  is  presumed  the  future  man  originates,  after  it  has  been 
fertilized  by  the  male  semen. 

The  Graafian  or  ovarian  vesicles  experience  considerable  changes 
during  menstruation,  conception,  and  after  impregnation.  The  inves- 
tigations of  Gendrin,  Negrier,  Pouchet,  Raciborski,  Jones,  Lee,  Pat- 
terson, Bischoff,  and  several  others,  have  led  to  the  belief,  which 
has  been  general  among  medical  men,  that  the  phenomena  of  men- 
struation is  owing  to  the  development  or  maturity  of  these  vesicles. 
Until  the  period  of  puberty  these  ovisacs  are  hardly  discernible,  but 
on  the  completion  of  this  period,  they  develop  themselves,  maturing 
periodically,  in  women  once  in  every  twenty-eight  days.  At  each 
period  of  ovulation  or  menstruation,  a  vesicle  becomes  much  enlarged, 
its  upper  segment  rapidly  rises  above  the  surface  of  the  ovary,  forming 
a  prominence  there  about  the  size  of  a  small  nut  (A,  Fig.  24),  and  the 
walls  of  the  vesicle  become  less  transparent  in  consequence  of  the 
thickness  of  the  internal  membrane,  and  the  hemorrhage  that  finally 
takes  place  in  the  interior  of  the  vesicle.  The  quantity  of  blood 
effused  within  the  vesicle  adding  to  the  amount  of  fluid  it  naturally 
holds,  distends  it  so  much  as  eventually  to  lacerate  or  rupture  its 
walls,  at  a  point  about  a  line  in  extent,  the  situation  of  which  can  be 
distinguished  by  its  reddish  appearance  and  its  more  elevated  pro- 
jection. The  ovum  and  contents  of  the  vesicle  escape  into  the  peri- 
toneal cavity,  or  are  carried  down  to  the  womb  by  the  Fallopian  tube : 
the  vesicular  walls  shrink  up,  their  cavity  holding  a  clot  of  blood 


88 


KING'S    ECLECTIC    OBSTETRICS. 


FIG.  24 


about  as  large  as  a  cherry,  which  has  oozed  from  the  torn  margins, 

and  which,  as  the  vesicular  cav- 
ity diminishes,  is  gradually  ab- 
sorbed. The  margins  of  the 
fissure  approximate,  giving  rise 
to  more  or  less  cicatricula  of 
various  forms,  being  sometimes 
linear,  again  radiated,  and  at 
others  triangular;  when  recent, 
they  are  red,  but  gradually  be- 
come brown,  forming  deep  fur- 
rows by  their  retraction. 
DIAGRAM  SHOWING  THE  OVARY,  AND  A  __  .  „  ,  .  , 

GBAAFIAK  VESICLE  AT  ITS  HIGHEST  BE-  This  rupture  of  the  vesiclea 
GREE  OF  DEVELOPMENT,  AND  JUST  BE-  not  only  takes  place  at  the  period 
FORE  ITS  RUPTURE.  of  impregnation,  but  also  at  each 

A.  The  hypertrophied  Vesicle  iod        f    ovulation  .      and     the 

B  C  C.  Radiated  cicatrices    left  by  previously  rup-    f 

tured  vesicles.  scars  which  are  left,  instead  of 

being  an  evidence  of  so  many  previous  conceptions,  as  was  formerly 
supposed,  are  merely  the  remains  of  ruptured  ovisacs.     (See  Nidation.) 


CHAPTER    XI. 

OF    THE    CORPUS    LUTEUM. 

THE  term  CORPUS  LUTEUM,  or  yellow  body,  is  applied  to  the 
remains  of  the  Graafian  vesicle,  after  the  ovum  has  been  expelled  from 
it,  whether  from  copulation  or  from  menstruation.  And  as  there  has 
been  considerable  discussion  upon  this  body,  regarding  its  presence  as 
a  sign  of  conception,  it  becomes  a  matter  of  some  moment,  in  a  medico- 
legal  point  of  view,  to  determine  its  true  character. 

The  corpus  luteum  is  a  peculiar  glandular  mass,  varying  in  size 
from  that  of  a  pea  to  half  an  inch  in  length ;  it  is  of  a  dull  yellow 
color,  friable  in  consistence,  having  a  lobulated  appearance,  with 
slight  convolutions,  somewhat  resembling  a  section  of  the  human 
kidney,  and  very  vascular ;  according  to  Montgomery,  an  injection 
through  the  spermatic  artery  will  easily  pass  into  its  substance.  The 
true  corpus  luteum  is  found  in  the  ovary  of  a  recently  pregnant  woman, 
and  varies  in  size  and  appearance  accord-ing  to  the  period  of  gestation, 


THE    CORPUS    LUTEUM.  89 

gradually  diminishing  in  size,  and  losing  its  deep  yellow  color,  until 
about  the  fifth  month  after  full  term,  when  it  disappears,  leaving  a 
small  pit  over  the  place  it  had  previously  occupied.  So  that  the  idea 
that  it  is  a  permanent  formation  is  erroneous.  Dr.  Montgomery,  who 
has  bestowed  considerable  attention  to  this  subject,  thus  speaks  of  its 
appearance : 

"  Its  center  exhibits  either  a  cavity,  or  a  radiated  or  branching  white 
line,  according  to  the  period  at  which  the  examination  is  made;  if 
within  the  first  three  or  four  months  after  conception,  we  shall,  I 
believe,  always  find  the  cavity  still  existing,  and  of  such  a  size  as  to 
be  capable  of  containing  a  grain  of  wheat  at  least,  and  very  often  of 
a  greater  dimension;  this  cavity  is  surrounded  by  a  strong  white  cyst; 
and,  as  gestation  proceeds,  the  opposite  parts,  of  this  cyst  approximate, 
and  at  length  close  together,  by  which  the  cavity  is  completely  oblit- 
erated, and  in  its  place  there  remains  an  irregular  white  line,  whose 
form  is  best  expressed  by  calling  it  radiated  or  stelliform.  This  is 
visible  as  long  as  any  distinct  trace  of  the  corpus  luteum  remains.  I 
am  unable  to  state  exactly  at  what  period  the  central  cavity  disappears 
or  closes  np,  to  form  the  stellated  line.  I  think  I  have  invariably 
found  it  existing  up  to  the  end  of  the  fourth  month.  I  have  one 
specimen,  in  which  it  was  closed  in  the  fifth  month,  and  another  in 
which  it  was  open  in  the  sixth — later  than  this  I  have  never  found  it. 

"  After  the  period  of  gestation  has  been  completed,  or  the  contents 
of  the  uterus  pi'ematurely  expelled,  so  that  gestation  ceases,  the  corpus 
luteum  soon  begins  to  exhibit  a  very  decided  alteration  in  all  its  char- 
acters, until,  at  length,  it  is  no  longer  to  be  found  in  the  ovary.  The 
exact  period  of  its  total  disappearance  I  am  unable  to  state ;  but  I 
have  found  it  distinctly  visible,  so  late  as  at  the  end  of  five  months 
after  delivery  at  the  full  time ;  but  not  beyond  this  period ;  and  the 
corpus  luteum  of  a  preceding  conception  is  never  to  be  found  along 
with  that  of  a  more  recent,  when  gestation  has  arrived  at  its  full  term; 
but  in  cases  of  miscarriage,  repeated  at  short  intervals,  it  may. 

"  At  the  time  of  delivery  the  corpus  luteum  is  neither  so  large  nor 
so  vascular  as  at  the  earlier  periods  of  pregnancy,  except  the  woman 
should  happen,  at  the  time  of  her  death,  to  be  laboring  under  inflam- 
mation of  the  uterine  system ;  in  which  case  the  corpus  luteum  partakes 
of  the  turgescence  of  the  other  parts,  and,  very  remarkably,  of  their 
increased  vascularity,  a  striking  instance  of  which  is  represented  in  a 
preparation  in  the  writer's  museum,  taken  from  the  body  of  a  woman 
who  died  of  inflammation  of  the  womb,  two  days  after  delivery;  the 
central  radiated  white  line  is  very  distinct,  and  the  vessels  having  been 


90  KING'S  ECLECTIC  OBSTETRICS. 

injected,  the  substance  of  the  corpus  luteum  is  quite  crimsoned,  and, 
externally,  the  ovary  continues  to  exhibit  the  superficial  cicatrix,  and 
the  alteration  of  form  produced  by  the  projection  of  the  part  contain- 
ing the  corpus  luteum." 

With  reference  to  the  corpus  luteum,  as  a  test  of  conception,  there  is 
some  diversity  of  opinion;  some  viewing  the  existence  of  a  true  corpus 
luteum,  so  called^  as  an  infallible  test;  while  others  maintain  that  no 
real  distinction  can  be  made  between  true  and  false  corpora  lutea,  or 
that  which  forms  independent  of  impregnation.  This  question  still 
remains  unsettled,  though  the  observations  of  Dr.  Montgomery,  which 
are  corroborated  by  other  investigators,  as  Haller,  Pouchet,  Haighton, 
Jones,  Lee,  Raciborski,  etc.,  seem  to  confirm  the  former  view;  he  re- 
marks :  "  I  have  seen  many  of  these  virgin  corpora  lutea,  as  they  are 
unhappily  called,  and  have  preserved  several  specimens  of  them ;  but 
not  in  any  one  instance  did  they  present  what  I  should  regard  as  even 
an  approach  to  the  assemblage  of  characters  belonging  to  the  true 
corpus  luteum,  the  result  of  impregnation,  from  which  they  differ  in 
all  the  following  particulars: 

"  1.  There  is  no  prominence  or  enlargement  of  the  ovary  over  them. 

"  2.  The  external  cicatrix  is  almost  always  wanting. 

"  3.  There  are  often  several  of  them  found  in  both  ovaries,  especially 
in  subjects  who  have  died  of  tubercular  disease,  such  as  phthisis,  in 
which  case  they  appear  to  be  merely  depositions  of  tubercle,  and  are 
frequently  without  any  discoverable  connection  with  the  Graafian 
vesicles. 

"  4.  They  present  no  trace  whatever  of  vessels  in  their  substance, 
of  which  they  are  in  fact  entirely  destitute,  and  of  course  can  not  be 
injected. 

"  5.  Their  texture  is  sometimes  so  infirm  that  it  seems  to  be  merely 
the  remains  of  a  coagulum,  and  at  others  appears  fibro-cellular,  like 
that  of  the  internal  structure  of  the  ovary;  but  never  presents  the  soft, 
rich,  lobulated,  and  regularly  glandular  appearance  which  Hunter 
meant  to  express,  when  he  described  them  as  '  tender  and  friable,  like 
glandular  flesh.' 

"  6.  In  form  they  are  often  triangular  or  square,  or  of  some  figure 
bounded  by  straight  lines. 

"  7.  They  never  present  either  the  central  cavity  or  the  radiated  or 
stelliform  white  line  which  results  from  its  closure. 

"This  latter  peculiarity,  in  common  with  several  others  observable 
in  these  spurious  productions  (whether  .occurring  in  virgins  or  in  other 
women,  but  not  the  result  of  conception),  even  when  they  are  connected 


THE    CORPUS    LUTEUM.  91 

with  a  Graafian  vesicle,  depends  on  their  different  mode  of  formation; 
a  circumstance  which  deserves  especial  attention,  as  pointing  out  the 
essential  difference  between  a  very  large  class  of  these  pseudo-structures 
and  the  true  ones. 

"  The  history  of  their  formation  appears  to  me  to  be  this :  accidental 
or  morbid  determination  takes  place  toward  a  vesicle,  in  consequence 
of  which  it  is  distended  with  fluid,  and  either  bursts  arid  discharges  its 
contents  (in  which  case  there  may  be  found  an  external  cicatrix),  or 
the  fluid  is  again  absorbed ;  but,  in  either  case,  there  is  often  deposited 
on  the  internal  surface  of  the  vesicle,  a  substance  somewhat  resembling 
the  corpus  luteum  in  color,  but  in  general  not  more  than  about  one- 
sixteenth  of  an  inch  in  thickness,  and  entirely  destitute  oi>  blood- 
vessels :  sometimes  it  is  very  much  thinner  even  than  this,  amounting 
to  little  more  than  a  mere  layer  of  coloring  matter  lining  the  vesicle. 
In  this  condition  I  have  often  found  them,  the  vesicle  being  enlarged 
to  three  or  four  times  its  natural  size,  full  of  fluid,  and  its  internal  sur- 
face of  a  bright  yellow  color;  but  when  the  vesicle  collapses,  either  in 
consequence  of  rupture  of  its  coats,  or  the  absorption  of  the  contained 
fluid,  the  inner  surface  of  this  new  deposit  closes  upon  itself,  and  forms 
an  irregular  line  of  junction,  which  is  generally  darker  than  the  rest 
of  the  structure,  and  not  unfrequently,  they  present  the  yellow  color 
only  on  the  circumference,  while  their  center  is  so  dark  as  to  be  almost 
black;  but,  from  their  situation,  they  are  entirely  without  lining  mem- 
brane, to  form  either  a  central  cavity  or  white  stellated  line,  which,  in 
the  true  corpus  luteum,  is  formed  by  the  closure  of  the  inner  coat  of 
the  vesicle;  for  the  same  reason  also,  these  accidental  formations  are  in 
general  much  smaller  than  the  others;  and  they  are  moreover  totally 
without  vessels  in  their  structure,  so-,  that,  however  minutely  the  rest 
of  the  ovary  may  be  pervaded  by  fine  injection,  not  a  particle  of  it  will 
pass  into  the  bodies  thus  formed." 

Among  those  who  have  not  considered  it  as  a  test  of  conception,  but 
only  as  an  evidence  of  perfect  ovulation,  may  be  named  Hume,  Blu- 
menbach,  Bischoff,  Cuvier,  Cazeaux,  Prof.  Meigs,  of  Philadelphia,  etc. 
This  latter  gentleman,  in  his  "Treatise  on  Obstetrics,"  maintains  that 
the  yellow  matter  found  in  a  corpus  luteum,  "is  of  the  same  apparent 
structure,  form,  color,  odor,  coagulability,  and  refractive  power,"  as 
the  yelk  of  eggs.  His  views  are  based  upon  the  following  observa- 
tions : 

"  1.  Equal  masses  of  yelk  and  corpus  luteum  are  equally  yellow. 

"  2.  They  alike  fill  the  tube,  before  the  focus  is  got,  with  a  brilliant 
yellow  light. 


92  KING'S  ECLECTIC  OBSTETRICS. 

"  3.  They  alike  consist  of  pellucid  fluid,  in  which  float  granules, 
corpuscles  containing  yellow  fluid,  oil-globules,  and  puuctiform 
bodies. 

'"  4.  These  bodies,  placed  on  the  same  platine,  and  diligently  com- 
]>;iiv<l  together,  exhibit  the  same  forms,  size,  tint,  and  refractive 
power. 

"  5.  Yelk,  boiled  hard,  is  granular  and  friable ;  it  is  coagulated  by 
heat. 

"  6.  Corpus  luteum,  boiled,  becomes  hard,  granular,  and  friable ;  it 
is  coagulated  by  heat. 

"  7.  Both  substances,  raw  or  boiled,  stain  paper  alike  of  a  yellow 
color. 

"  8.  There  is  this  difference :  the  crushed  mass  of  corpus  luteum 
contains  patches  of  laminar  cellular  tela,  detritus,  and  blood-disks 
forced  out  by  the  compressorium ;  which  can  not  occur  in  the  yelk,  as 
that  is  contained  within  a  vitellary  membrane,  in  which  its  corpuscles 
are  free ;  whereas,  in  the  corpus  luteum,  they  are  confined  by  the  deli- 
cate cellular  substance  lying  betwixt  the  concentric  laminae  of  the 
Graafian  follicle. 

"  9.  They  refract  alike. 

"  10.  Projected  on  a  live  coal,  they  alike  give  out  the  odor  of  roasted 


These  opinions  require  further  investigation,  in  order  to  establish 
their  correctness. 

The  formation  of  the  true  corpus  luteum,  is  thus  explained  by 
Ramsbotham :  "  It  has  been  demonstrated  that  the  Graafian  vesicle 
possesses  two  membranes :  one.  adhering  to  the  substance  of  the 
ovary,  the  other  inclosing  the  fluid  in  which  the  ovule  of  Baer 
floats.  When  a  fruitful  connection  takes  place,  a  great  determination 
of  blood  is  made  to  that  ovary  which  supplies  the  germ.  The 
gland  becomes  larger,  rounder,  and  more  vascular  than  the  other  ; 
to  the  touch  it  feels  fuller  and  softer.  But  the  vascularity  is  con- 
fined to  one  spot — the  neighborhood  of  the  corpus  luteum ;  and  the 
increased  size  and  softness  result,  not  so  much  from  an  alteration  in 
the  structure  of  the  whole  organ,  as  from  the  quantity  of  lymph  and 
fluid  blood  deposited  between  the  membranes  of  the  vesicle,  which  is 
converted  into  the  characteristic  yellow  gland-like  mass.  This  effusion 
causes  the  vessel  to  be  thrown  prominently  out  toward  the  peritoneal 
surface;  the  attenuated  coats  burst,  or  rather  an  opening  is  formed  by 


THE    CORPUS    LUTEUM.  93 

absorption,  and  the  fluid,  with  the  ovule  previously  contained  within 
them,  passes  into  the  tube." 

The  changes  that  occur  in  the  ovisac  take  place  with  less  intensity 
when  impregnation  is  not  present,  and  hence  the  difference  in  the 
appearance  between  the  true  and  false  corpora  lutea.  AVhen  impreg- 
nation has  taken  place,  there'  is  increased  vascular  excitement  in  the 
ovaries  and  uterus;  and  from  the  augmented  accumulation  of  blood  in 
the  generative  parts,  the  changes  in  the  ovisac  occur  with  more  slug- 
gishness, because  they  are  "  conducted  upon  a  larger  scale  and  with  a 
greater  abundance  of  materials." 

Leishman,  in  his  System  of  Midwifery,  closes  a  very  able  article  on 
this  subject  as  follows : 

"  What  is  called  the  Corpus  Luteum  is  due  to  a  deposit  of  yellow 
fatty  matter  in,  and  hypertrophy  of,  the  internal  layer  of  the  Graafian 
vesicle  (ovisac). 

"  The  formation  of  a  corpus  luteum  always  succeeds  the  rupture  of 
a  Graafian  vesicle. 

"  Up  to  a  certain  point  the  changes  in  the  Graafian  vesicle  are  uni- 
form, and  have  no  relation  to  pregnancy.  The  corpus  luteum  of  preg- 
nancy may,  however,  be  distinguished  in  its  subsequent  course  by  its 
higher  development  and  longer  duration,  its  hardness,  its  vascularity, 
and,  at  a  later  stage,  by  the  formation  of  the  white  lining  membrane, 
and  large  central  stellate  cicatrix. 

"  The  presence  in  the  ovary  of  a  corpus  luteum  is  no  evidence  of 
pregnancy,  unless  the  characteristics  last  indicated  are  distinct  and 
unequivocal — under  which  circumstance  it  is  a  certain  sign. 

"  With  reference  to  the  above  conclusions,  it  may  be  remarked  that 
much  confusion  has  arisen  from  the  employment  loosely  of  the  terms 
'true'  and  'false,'  as  applied  to  the  corpus  kiteum,  in  so  far  as  they 
are  assumed  to  imply  a  distinction,  which  proves  or  disproves  the  oc- 
currence of  pregnancy. 

"  '  There  is  as  little  reason,'  says  Farre,  with  justifiable  emphasis, '  for 
the  use  of  the  last  term  as  there  would  be  for  denominating  a  child  a 
false  man.  .  .  .  These  terms  actually  represent  the  same  body, 
only  in  different  stages  of  growth  or 'decay/ 

"During  the  whole  of  the  child-bearing  period  of  a  woman's  life, 
the  ripening  and  dehiscence  of  the  Graafian  vesicles  are  of  periodic 
occurrence.  In  those  animals  in  which  plural  births  are  the  rule,  sev- 
eral vesicles  ripen  and  discharge  their  contents  at,  or  near,  the  same 
time;  but  in  man  this  is  exceptional, and  we  thus  find  that  one  vesicle 


94  KING'S  ECLECTIC  OBSTETRICS. 

only,  as  a  rule,  ripens  at  a  time,  bursts,  discharges  its  contents,  and 
rapidly  shrinks  as  it  retires  toward  the  centre  of  the  ovary,  to  give 
place,  in  a  normal  condition  of  the  parts,  to  a  constant  succession  of 
vesicles,  which,  one  by  one,  run  a  similar  course  after  discharging  their 
ova.  There  is  every  reason  to  believe,  further,  that,  during  pregnancy 
and  stickling,  while  the  uterine  functions  are  in  abeyance,  those  also 
of  the  ovary  are  temporarily  arrested,  in  so  far  as  the  development  of 
new  Graafian  vesicles  is  concerned — the  whole  generative  force  being, 
as  it  were,  turned  into  other  channels. 

"The  numerous  lacerations  which,  in  consequence  of  repeated  rup- 
tures, take  place  on  the  surface  of  the  ovary,  leave,  in  the  process  of 
healing,  corresponding  cicatrices.  On  this  account,  the  smoothness 
of  surface  is  soon  lost,  and  it  becomes  more  and  more  fissured  and 
wrinkled,  until,  toward  the  end  of  the  child-bearing  epoch  in  a  wo- 
man's life,  the  ovary  is  so  irregular  on  the  surface,  as  to  warrant  the 
comparison  which  Raciborski  has  instituted  between  it  and  the  kernel 
of  a  peach.  After  this,  the  organ  becomes  atrophied,  and,  like  the 
uterus  and  other  parts,  is  restored,  in  some  measure,  to  the  form  which 
it  presented  in  early  life." 

The  medical  expert,  if  called  upon  to  determine  the  existence  or  non- 
existence  of  pregnancy,  by  the  appearance  of  the  corpus  luteum  in  a 
post-mortem  examination,  would  undoubtedly  find  an  extremely  diffi- 
cult question  to  decide.  Every  author  cites  numerous  differential 
characteristics,  which  I  believe  to  be  misleading ;  also  impossible  to 
diagnose  pregnancy,  beyond  the  peradventure  of  doubt,  simply  by  the 
appearance  of  the  corpus  luteum. 


CHAPTER   XII. 

THEORIES   OF   IMPREGNATION. 

GENERATION  comprises  those' several  phenomena  which  are  neces- 
sary to  the  development  or  reproduction  of  organized  bodies,  and  which 
include,  in  the  human  family,  the  various  functions  of  menstruation, 
copulation,  conception,  gestation,  and  labor  or  parturition.  The  partic- 
ular method  by  which  generation  is  effected  in  the  organic  world, 
varies  according  to  the  character  of  the  organization,  being  more  sim- 


THEORIES    OF    IMPREGNATION.  95 

pie  as  this  approaches  elementarity.     Moreau  has  described  the  several 
modes  somewhat  as  follows: 

1.  Generation  may  be  spontaneous,  doubtful  or  unknown,  as  in  case 
of  intestinal  worms. 

2.  It  may  result  from  an  individual,  by  division  or  separation  of  its 
parts;   a,  by  simple  division  of  the  individual,  each  fragment  pro- 
ducing a  new  individual,  as  in  the  instances  ofjissiparce  or  vegetables, 
cuttings  of  trees,  and  animal  infusoria;  6,  by  separation  of  a  vegetable 
product,  either  on  the  exterior  or  interior  of  the  individual,  as  with 
the  gemmiparce,  or  vegetables,  buds  of  trees,  and  some  polypi. 

3.  It  may  be  effected  by  impregnation,  requiring  the  connection  of 
the  sexes,  and  varies  according  to  the  character  of  the  sexes.     1st. 
As  in  hermaphrodism,  or  where  the  sexes  are  united  in  the  same  indi- 
vidual, and  which  may  be  divided  into,  «,  where  the  sexes  are  united 
in  a  common  envelope,  in  which  instance  one  individual  is  sufficient, 
as  with  many  vegetables  and  some  molusca;  6,  where  the  sexes  are 
separated  on  the  same  individual,  as  in  monoecious  plants;  c,  with  the 
sexes  separated  in  the  same  individual,  but  requiring  the  connection 
of  two  similar  individuals,  and  even  reciprocal  impregnation,  as  with 
gasteropodous  mollusca,  and  worms.     2d.  When  the  sexes  are  sepa- 
rated on  different  individuals,  and  which  may  be  divided  into,  a,  with- 
out approximation,  the  parents  and  offspring  remaining  unknown  to 
each  other,  as  with  dioecious  plants,  and  fishes ;  6,  with  approximation, 
but  without  copulation,  the  parents  knowing  each  other,  but  the  off- 
spring being  ignorant  of  them,  as  with  the  batrachia,  or  reptiles,  frogs, 
toads,  etc.;  c,  with  approximation  and  copulation,  as  with  the  majority 
of  insects;  the  reptilia,  chelonia,  sauria,  ophidia,  birds,  and  mammalia. 

4.  This  last  method  of  generation  by  copulation  and  approximation, 
offers  great  varieties,  differing  according  to  the  mode  of  development 
of  the  fecundated  product,  thus:  a,  by  incubation,  as  with  insects,  and 
the  greater  part  of  reptiles  and  fishes ;  6,  by  external  incubation,  as 
with  birds;  c,  by  internal  incubation  in  the  parts  of  the  mother,  with- 
out adhering  to  them,  as  with  some  of  the  ophidian,  and  ovovivipa- 
rous  animals;  d,  by  an  organ  of  gestation,  to  which  the  impregnated 
product  adheres,  from  which  it  derives  the  greater  part  of  its  nourish- 
ment, and  from  which  it  separates  after  a  certain  time,  as  with  all  the 
mammiferous  animals.     To  this  last  and  most  complicated  process 
belongs  the  generation  of  man. 

The  mode  in  which  fecundation  is  accomplished  in  the  human  being 
belongs  more  especially  to  the  physiologist's  department  to  determine; 


96  KING'S  ECLECTIC  OBSTETRICS. 

but  as  the  matter  has  long  been  a  subject  of  inquiry,  and  presents  a 
field  of  interest  to  many,  I  will  briefly  refer  to  the  various  opinions 
that  have  from  time  to  time  been  advanced  and  maintained  in  the 
medical  world. 

In  the  male,  the  semen,  or  spermatic  fluid  secreted  by  the  testicles, 
is  undoubtedly  the  agent  especially  called  into  action  in  the  function 
of  reproduction ;  this  is  manifest  from  the  fact  that,  removal  of  the 
testes  not  only  destroys  all  sexual  propensity,  but  likewise  renders  the 
individual  forever  after  incapable  of  begetting  offspring:  The  same 
may  be  said  in  relation  to  the  removal  of  the  ovaries  of  the  female ; 
she  loses  all  sexual  inclination,  the  procreative  functions  are  annihi- 
lated, and  all  those  graces,  emotions,  and  feelings  which  distinguish 
the  sex,  gradually  disappear.  Observations  have  likewise  been  made 
in  relation  to  this  matter,  of  a  highly  interesting  character,  to  some 
of  which  a  very  concise  reference  will  here  be  made. 

Spallanzani,  during  his  investigations,  noticed,  that  as  soon  as  the 
female  frog  laid  an  egg,  the  male  immediately  cast  a  fluid  upon  it, 
which  soon  impregnated  it.  He  then  confined  the  gentials  of  the 
male  frog  in  a  silk  bag,  and  ascertained  that  in  this  condition  impreg- 
nation could  not  occur.  He,  likewise,  applied  to  some  of  the  freshly 
laid  ova,  a  small  quantity  of  the  male  semen  or  fluid  which  he  had 
previously  collected,  and  impregnation  was  the  result.  He  also  insti- 
tuted similar  experiments  on  a  bitch  in  heat,  and  which  had  been  kept 
confined  for  twenty-three  days  before  heat  commenced,  in  order  to 
prevent  the  approach  of  any  dog ;  the  result  was,  that  by  injecting 
nineteen  grains  of  semen  into  the  vagina,  at  100°  Fah.,  fecundation 
followed,  and,  at  the  proper  period,  the  animal  gave  birth  to  three 
pups  which  bore  a  strong  resemblance  to  herself  and  the  dog  from 
which  the  semen  was  gathered.  Prevost  and  Dumas  arrived  at  simi- 
lar results ;  they  expressed  the  semen  from  the  testicle  of  a  frog,  and 
after  diluting  it  with  water,  they  placed  some  ova  upon  it,  which  be- 
came prolific.  According  to  these  gentlemen,  it  is  important  to  dilute 
the  male  fluid  in  order  to  have  the  experiment  prove  successful. 

Sir  Everard  Home,  in  his  "  Lectures  on  Comparative  Anatomy," 
vol.  iii,  p.  315,  records  a  similar  experiment  on  man,  performed  by 
Hunter ;  the  husband  was  affected  with  hypospadias,  which  prevented 
him  from  impregnating  his  wife;  Hunter  advised  him  to  inject  his 
semen  into  his  wife's  vagina  through  a  warm  syringe ;  the  result  was, 
she  became  pregnant. 

These  experiments,  with  others  of  similar  character,  prove  conclu- 


THEORIES    OF    IMPREGNATION.  97 

sively,  that  the  agents  engaged  in  the  generating  process,  are  the  semen 
furnished  by  the  male  testes,  and  the  ova  of  the  female.  Spallanzani, 
as  well  as  Prevost  and  Dumas,  determined  from  further  and  satisfac- 
tory trial,  that  the  fructification  of  the  ova  only  took  place  when 
brought  into  actual  contact  with  the  male  semen ;  thus  refuting  the 
doctrine  held  by  some  physiologists,  that  impregnation  did  not  require 
this  mutual  junction,  but  was  effected  merely  by  the  presence  or  influ- 
ence of  a  seminal  halitus  or  vapor. 

Another  point  of  inquiry  among  physiologists,  was,  the  method  by 
which  the  spermatic  fluid  is  carried  to  the  ovaries;  some  contending 
that  impregnation  was  effected  in  the  uterus,  while  others  maintained 
that  the  semen  was  conducted  to  the  ovaries,  and  that  fecundation  was 
possible  even  beyond  the  angles  of  the  uterus;  indeed,  this  fluid  has 
been  found  on  the  surface  of  the  ovaries,  by  Adelon,  Bischoff,  and 
other  investigators.  But  by  what  means  it  reaches  the  ovaries,  has 
never  yet  been  satisfactorily  explained;  for  the  male  penis,  certainly 
has  not  sufficient  power  to  throw  it  beyond  the  uterus. 

Various  views  have  likewise  been  supported  at  different  periods, 
relative  to  the  manner  in  which  the  union  of  the  male  and  female 
principles  necessary  to  the  formation  of  a  new  being,  is  effected,  and 
how  this  new  being,  of  whatever  species,  comes  to  bear  the  impress  of 
the  mental  and  physical  features  of  one  or  both  parents.  But  the 
solution  of  these  particulars  is  still  involved  in  mystery.  The  oldest 
theory  on  this  subject,  is  that  of  epigenesis,  which  holds  that  the  new 
being  is  created  entirely  anew,  and  at  the  moment  of  conception, 
receives  at  once  the  materials  necessary  for  its  formation,  one  portion 
being  derived  from  the  testes  of  the  male  parent,  the  other  from  the 
uterus  or  ovaries  of  the  female.  Aristotle,  Galen,  and  others,  sup- 
posed that  the  material  furnished  by  the  female  was  the  menstrual 
fluid;  and  Hippocrates  considered  that  the  female  supplied  all  the 
substance  required  for  the  development  of  the  future  being,  while  the 
male  fluid  merely  contained  that  vivifying  principle  necessary  to  im- 
part vitality  to  the  female  materials.  This  theory  of  epigenesis,  with 
various  modifications,  was  the  prevailing  one  for  many  years,  and  was 
for  a  time  renewed  by  Buffon  in  the  beginning  of  the  seventeenth 
century,  whose  views  were  entirely  speculative  and  untenable.  His 
notion  was,  that  the  growth  and  nourishment  of  individuals  during 
youth,  was  effected  by  certain  organic  molecules  common  to  both 
sexes ;  but  which  being  required  in  less  quantities  for  these  purposes 
at  maturity,  the  predominance  was  emitted  by  the  male  testes  with  the 
7 


98  KING'S  ECLECTIC  OBSTETRICS. 

spermatic  fluid,  and  also  by  the  ovaries,  or  female  testes,  as  he  termed 
them,  for  the  purposes  of  reproduction  of  the  species.  He  imagined 
that  the  body  of  each  parent  supplied  each  of  these  molecules  with 
atoms  derived  from  its  various  parts,  and  that  whichever  parent  af- 
forded to  the  newly  organized  being  the  major  portion  of  these  mole- 
cules, the  resemblance  to  that  parent  would  be  the  most  marked. 

During  the  sixteenth  century  another  theory  was  originated,  being 
based  upon  investigations  and  discoveries  of  the  physiologists  of  that 
period,  among  whom  may  be  named,  Leuwenhoeck,  Harvey,  De  Graaf, 
and  others.  It  is  termed  the  theory  of  evolution;  and  was  strenuously 
supported  under  some  form  or  other,  during  the  whole  of  this  century. 
The  adherents  of  this  theory  maintained  that  the  germ  of  the  new 
being  existed  in  only  one  of  the  parents,  while  the  other  furnished  the 
principle  which  communicated  life  to  it.  They  were  divided  into 
ovarists,  and  animalculists  or  spermatists.  The  ovarists,  among  whom 
I  may  mention  Harvey  as  the  principal,  having  discovered  numerous 
small  vesicles  in  the  ovaries,  which  apparently  decrease  according  to 
the  number  of  conceptions,  held  that  these  vesicles  were  the  fetal 
germ,  which  only  needed  the  animating  power  of  the  male  semen  to 
usher  the  new  being  into  existence.  But  this  view  was  objected  to  by 
many,  on  account  of  its  exclusiyeness,  whereby  the  male  fluid  had  but 
a  minor  part  to  perform;  beside  which,  if  the  semen  merely  exerted  a 
vivifying  influence  upon  these  vesicles,  it  did  not  explain  why  the 
offspring  so  often  resembled  its  male  parent. 

In  consequence  of  these  objections,  a  different  opinion  was  supported 
by  those  who  were  called  animalculists,  and  which  originated  princi- 
pally from  the  microscopic  discoveries  of  Leuwenhoeck  and  other  in- 
vestigators, who  found  myriads  of  animalcules  in  the  male  semen. 
These  held,  that  after  having  been  thrown  into  the  uterus  during  copu- 
lation, the  animalcules  perished,  with  the  exception  of  one  or  two, 
which  entering  the  Fallopian  tubes/ were  conveyed  through  to  the 
ovaries,  and  there  deposited  and  nourished  in  a  nidus  formed  by  the 
ovum.  As  this  spermatozoid  progressed  in  growth,  it  ruptured  the 
nidus  which  inclosed  it,  and  was  again  conveyed  to  the  uterus  to  be 
nourished  and  preserved  until  the  period  of  parturition.  To  this 
view,  wherein  the  female  merely  supplies  the  nourishment  for  the 
embryo  furnished  by  the  male,  an  objection  similar  to  the  one  above 
is  suggested,  as  to  the  cause  of  resemblance,  in  many  instances,  to  the 
female  parent. 

Those  who  desire  to  have  these  several  views  more  in  detail,  are 


THEORIES    OF    IMPREGNATION.  99 

referred  to  the  several  physiological  treatises  in  which  they  are  fully 
related  and  discussed ;  and  as  they  have  become  at  the  present  day 
obsolete,  a  mere  glance  at  them  was  deemed  all-sufficient  in  the  pres- 
ent work.  But,  before  terminating  this  subject,  a  reference  to  the 
views  of  physiologists  of  the  present  day  must  be  made,  without  which, 
this  portion  of  our  work  would  be  imperfect. 

In  Chapter  X,  will  be  found  a  description  of  the  ovaries,  Graafian 
vesicle,  ovule,  germinal  spot,  etc.;  these  are  the  discoveries  of  recent 
physiological  investigators,  and  have  been  the  means  of  eifecting  a 
revolution  in  relation  to  the  views  of  impregnation,  giving  rise  to  a 
theory,  the  ovular  theory,  which  is,  undoubdtedly,  more  in  proximity  to 
the  truth,  than  any  of  the  previous  doctrines  which  have  been  held  on 
this  subject.  The  theory  is,  that  the  egg,  ovum  or  germ,  is  supplied  by 
the  female,  in  whom  it  exists  in  indeterminate  quantities ;  that  at  the  age 
of  puberty,  these  germs  commence  maturing;  at  their  period  of  ripen- 
ing, they  rupture  the  vesicular  tissue  in  which  they  are  contained  and 
pass  from  it,  being  accompanied  by  a  sanguineous  discharge,  probably 
from  the  uterus,  called  menstruation,  the  appearance  of  which  is  signifi- 
cant of  the  fact,  that  the  female  has  reached  the  age  at  which  she  is  capa- 
ble of  giving  birth  to  children ;  these  ovules  escape  either  into  the  peri- 
toneal cavity,  or  into  the  womb  through  the  Fallopian  tubes,  and  pass 
off  with  the  menstrual  flow,  or  are  retained  in  consequence  of 
fecundation. 

On  the  other  hand,  the  male  supplies  a  fluid  in  which  is  contained 
minute,  round  and  granulated  bodies,  the  spermatic  granules,  as  well  as 
bodies  possessed  of  motion,  like  the  epithelial  cells,  which  are  not,  how- 
ever, animalcules,  but,  more  properly,  spermzoons  or  spermatozoids ; 
these  bodies,  by  means  of  ciliary  movement,  the  result  of  wavy  motion  of 
the  ciliated  epithelium  lining  the  walls  of  the  uterus  and  of  the  Fallo- 
pian tube,  assisted  perhaps  by  a  kind  of  peristaltic  action  of  the  latter, 
are  conveyed  to  the  uterus,  tubes,  or  ovaries,  when  coming  into  contact 
with  the  nude,  uncovered  ovum — wherever  this  may  be,  in  the  ovary, 
the  tube,  or  the  uterus — through  some  inscrutable  agency,  probably 
an  intermingling  or  mutual  permeation  of  the  male  semen  and  female 
germ,  animalization  takes  place ;  and  a  creature  is  brought  into  exist- 
ence, which,  possessing  certain  elements  derived  from  each  parent,  will, 
necessarily,  present  mental  and  physical  resemblances  to-either  or  both 
of  them.  Ovarian  and  ventral  pregnancy  prove  that  the  spermzoons 
are  conveyed  even  to  the  ovary ;  but  impregnation  undoubtedly  occurs 
in  the  tube  or  in  the  uterus — after  the  ovum  has  left  its  ovarian  vesicle. 


100  KING'S  ECLECTIC  OBSTETRK  s. 

How  long  a  period  is  occupied  between  the  emission  of  the  ovum  from 
the  ovary  and  its  entrance  into  the  uterine  cavity  is  unknown,  proba- 
bly five  or  six  days. 

Repeated  experiments  on  animals  have  proved,  that  any  obstacle  to 
this  contact  of  the  germ  and  semen,  will  prevent  conception.  Martin, 
Barry,  Bischoff,  and  others  have  observed  the  spermzoons  freely  mov- 
ing about  in  the  transparent  zone  of  recently  impregnated  ova  of  ani- 
mals, and  it  is  by  no  means  improbable  that  a  similar  result  occurs  in 
impregnation  of  human  ova. 


CHAPTER   XIII. 

MENSTEUATION — OVULATION — CONCEPTION. 

AT  a  certain  age,  the  female  reaches  the  period  of  puberty,  which  is 
made  manifest  by  a  sanguineous  discharge  from  the  uterus,  occurring 
periodically  once  a  month,  and  which  is  called  menstruation.  It  has 
likewise  many  other  names  applied  to  it — as  menses,  catamenia,  courses, 
terms,  periods,  monthly  sickness,  menstrua,  flowers,  monthlies,  times,  etc. 
It  is  not  a  secretion,  but  an  effusion  or  hemorrhage;  very  much  resem- 
bling venous  blood,  and  is  undoubtedly  blood  rendered  impure  by  the 
addition  of  mucus  and  epithelial  scales  with  which  it  meets  during 
its  flow. 

Strieker,  of  Vienna,  "  has  demonstrated  the  passage  of  red  and 
white  blood  corpuscles,  through  the  walls  of  the  capillaries  of  the  uter- 
ine mucous  membrane.  Some  of  these  capillaries  become  ruptured  in 
the  process.  The  blood  oozes  through  the  mucous  membrane  of  the 
uterine  cavity,  impregnates  its  epithelium,  causing  it  to  swell  and  be- 
come detached,  and  passes  on,  mixed  with  epithelial  debris,  into  the 
vagina,  and  thence  out  of  the  body." 

As  a  general  rule,  the  discharge,  in  females  of  this  climate,  is  estab- 
lished at  the  fourteenth  or  fifteenth  year,  though  it  varies  with  some, 
oftentimes  appearing  as  early  as  the  twelfth  or  thirteenth  year,  and 
again  not  until  the  seventeenth  or  eighteenth.  In  the 'former  instance, 
it  is  termed  precocious  menstruation,  and  is  significant  of  an  unnatural 
increase  or  development  of  certain  organs,  at  the  expense  of  others;  it 
is  commonly  followed  by  premature  death,  especially  if  an  early  mar- 
riage, resulting  in  pregnancy,  should  take  place,  in  consequence  of 


MENSTRUATION OVTILATION CONCEPTION.  1 01 

these  unseasonable  and  abnormal  indications  of  puberty.  In  the  latter 
instance,  the  term  tardy  menstruation  is  applied,  and  which  is  usually 
the  result  of  some  debility  or  disease,  that  may  eventually  destroy  the 
female. 

Climate,  constitution,  education,  modes  of  life,  etc.,  affect  the  ap- 
pearance of  this  discharge;  it  being  earlier  in  warm  climates  than  in 
•cold,  and  i-n  city  females,  than  in  those  of  the  country.  It  likewise  ap- 
pears earlier  and  more  abundantly  in  females  of  a  nervous  tempera- 
ment, than  in  those  who  are  phlegmatic. 

The  advent  of  the  menstrual  discharge,  is  the  chief  external  sign  of 
the  approach  of  puberty;  and  is  one  of  the  most  interesting  periods  in 
the  life  of  the  female.  At  this  time,  a  Graafiau  vesicle  for  the  first 
time  projects  from  the  surface  of  the  ovary,  gradually  developing  to  a 
state  of  complete  maturity,  the  maturation  of  which  marks  an  impor- 
tant epoch  in  the  life  of  the  female — a  transformation  in  which  the  girl 
passes  into  womanhood  and  becomes  capable  of  reproduction,  a  process 
attended  by  growth  and  development  of 'the  peculiar  organism  of  the 
female  —  by  which  a  new  life  and  individuality  assert  themselves. 
Thus  ovulation  is  established,  which,  at  puberty,  is  usually  concurrent 
with  menstruation,  and  is  probably  the  immediate  or  exciting  cause  of 
menstruation ;  however,  as  will  be  seen  presently,  the  two  may  exist 
independently  of  one  another.  This  interesting  period,  in  the  life  of 
the  female,  is  ushered  in  by  many  symptoms  and  changes  in  her  mental 
and  physical  developments  that  manifest  themselves  gradually.  A  re- 
markable advancement  toward  the  perfection  of  the  reproductive  organs 
is  presented ;  the  ovaries  rapidly  enlarge,  and  change  from  their  pre- 
vious long,  flat,  and  smooth  condition,  to  one  in  which  they  are  large, 
oval,  rounded,  and  embossed;  the  Fallopian  tubes  become  elongated, 
their  fimbriated  extremities  widened,  and  the  fimbriae  enlarged;  the 
uterus  becomes  more  fully  supplied  with  blood,  and  its  tissue  more 
florid;  the  body  and  fundus  likewise  obtain  more  rotundity  and  devel- 
opment than  the  cervix,  which  appears  proportionally  shorter  and  nar- 
rower; the  vagina  is  widened  and  dilated,  and  its  vascular  structure  is 
supplied  with  increased  quantities  of  blood,  and  its  mucous  folds  aug- 
ment in  number.  The  pelvis  becomes  larger  and  wider,  with  a  dimi- 
nution of  its  inclination  forward;  the  pubic  region  more  prominent, 
round  and  covered  with  hair;  the  labia  pudendi  more  amplified,  red, 
and  sensitive;  the  hips  more  projecting,  and  inclined  outwardly;  the 
pelvic  cavity  enlarged ;  and  the  breasts  rounder,  full,  and  prominent, 
with  the  nipples  projecting,  more  sensitive,  and  the  areola  of  a  darker 


102  KING'S  ECLECTIC  OBSTETRICS. 

hue.     The  whole  person  improves  in  grace  and  elegance,  and  the  voice 
becomes  more  sonorous  and  melodious. 

Corresponding  with  these  modifications  of  the  physical  system,  are, 
changes  in  the  mental  character;  the  gay,  light-hearted  girl  loses  her 
playfulness,  and  assumes  the  dignity  of  womanhood ;  she  becomes  more 
reserved,  more 'sensitive,  and  full  of  sympathy;  she  manifests  strong 
attractive  feelings  toward  the  opposite  sex,  and  seeks  to  love,  as  well  as 
to  be  loved;  the  social  and  moral  sentiments  become  of  a  purer  and 
more  exalted  character;  a  great  fondness  for  children  is  displayed  ;  and 
in  her,  we  find  the  most  perfect  combination  of  modesty,  devotion,  pa- 
tience, affection,  gratitude,  loveliness,  and  Christian  virtue. 

The  menstrual  discharge,  being  a  sign  of  maturity  and  fertility  of 
the  reproductive  organs,  does  not  appear  during  childhood,  nor  in  old 
age.  It  usually  ceases  at  the  ages  of  from  forty  to  fifty,  though  occa- 
sionally, it  extends  to  a  very  advanced  age.  The  period  of  its  cessation 
is  termed  the  turn  of  life,  the  menopause,  or  the  critical  time  of  life ;  from 
which  time,  women  cease  to  bear  children.  And  on  account  of  the  vari- 
ous unpleasant,  and  often  serious  symptoms  presenting  at  this  period, 
its  approach  is  much  dreaded  by  nearly  all  of  them. 

The  amount  of  fluid  discharged,  varies  in  females,  averaging  from 
six  to  eight  ounces;  some -will  lose  only  four  ounces  at  each  menstrua- 
tion, and  others  twelve,  and  yet  each  will  remain  in  health,  because 
the  system  of  each  is  controlled  and  affected  according  to  its  individ- 
ual wants,  habits,  strength,  and  activity.  The  discharge  usually  con- 
tinues from  three  to  six  days,  occasionally  from  eight  to  ten,  and  must, 
as  a  general  rule,  have  revealed  itself  before  impregnation  can  take 
place. 

All  cleanly  women  \vcar  a  napkin  during  menstruation,  which  is 
placed,  by  means  of  a  girdle,  in  a  manner  similar  to  a  T  bandage,  for 
the  purpose  of  concealing  their  situation,  which  it  does  by  absorbing 
the  fluid  discharged;  from  four  to  twenty  of  these  napkins  will  be 
worn  during  one  menstrual  term. 

In  the  consideration  of  menstruation  and  ovulation,  many  strange 
theories  have  been  advanced,  that  appear  quite  absurd  in  the  light  of 
modern  research;  some  authors  use  the  terms  synonymously.  Physi- 
ological investigation,  however,  gave  rise  to  such  inquiries  as :  What 
is  the  cause  of  menstruation?  From  whence  comes  the  hemorrhage? 
To  what  extent  does  menstruation  depend  on  ovulation  ?  Is  the  ani- 
mal rut,  or  oestrus,  and  menstruation,  analogous?  And  many  other 
questions  that  we  need  not  notice  here. 


.MENSTRUATION OVULATIOX CONCEPTION.  103 

Menstruation  is  believed  by  many  to  be  merely  the  phenomenon  of 
that  function  which  matures  and  discharges  an  ovum  from  the  ovary 
periodically.  The  prevailing  belief  seems  to  be,  that  menstruation  is 
co-existent  with,  or  rather  the  result  of,  functional  ovarian  activity ;  that 
menstruation  is  an  indication  of  ovulation.  That  ovulation  occurred 
only  at  the  menstrual  period,  \vas  generally  accepted  as  a  fact,  until 
within  a  few  years.  It  is  a  special  function,  and  consequently  may  oc- 
cur independently  of  menstruation ;  causes,  of  which  we  know  nothing, 
may  hasten  the  development  of  a  vesicle,  or  excite  the  bringing  forth 
of  an  immature  ovum,  and  thus  establish  —  inter-menstrual  ovulation. 

The  Jewish  female  furnishes,  it  seems,  evidence  indicating  the  occur- 
rence of  inter-menstrual  ovulation.  According  to  Rabbinical  ruling, 
intercourse  is  prohibited  until  twelve  days  after  the  appearance  of 
menstruation ;  at  the  expiration  of  this  time,  the  bath  of  purification 
is  taken,  the  Jewess  scrupulously  cleansing  herself — every  part  of  the 
body  being  immersed  in  the  bath.  Mosaic  law  has  named  this  the 
Micva.  Not  until  now,  does  the  wife  receive  the  husband.  These 
women  are  surely  as  prolific  as  other  females,  and  their  impregnation 
demonstrates  the  fact,  that  the  maturation  of  the  ova  occurs  at  any 
time. 

A  Graafian  vesicle  may  rupture  during  sexual  excitement,  as  during 
coitus,  or  from  the  sequence  of  such  excitement;  and  this  is  an  ex- 
planation why  women  may  conceive  at  any  time.  That  ova  are  dis- 
charged at  irregular  periods  from  the  ovaries,  and  not  merely  monthly, 
about  the  menstruating  period;  that  there  can  be  no  menstruation 
except  in  connection  with  ovulation,  though  there  may  be  oyulation 
without  menstruation,  is  now  becoming  the  opinion  of  obstetricians  in 
general. 

Mr.  Lawson  Tait  says :  "  The  growth  and  ripening  of  Graafian  folli- 
cles before  puberty  constitutes  one  of  the  many  arguments  in  favor  of 
the  view,  that  menstruation  and  ovulation  are  wholly  distinct  processes, 
and  abundant  examples  can  be  given  of  them  being  carried  on  each 
independently  of  the  other.  The  statement  constantly  made  in  text- 
books that,  if  the  ovaries  are  extirpated,  or  become  atrophied,  men- 
struation does  not  re-appear,  is  not  accurate ;  and  equally  incorrect  is 
the  assertion  that  the  first  ovular  dehiscence  corresponds  with  the  first 
appearance  of  the  menses.  It  is  perfectly  certain,  that  ovulation  is  by 
no  means  a  periodic  process,  in  the  sense  of  being  monthly;  and  the 
fact  that  a  periodic  flow  from  the  uterus  is  almost  confined  to  the  hu- 
man race,  is  sufficient  to  show,  that  it  is  not  in  the  ovaries  that  we 


104  KING'S  ECLECTIC  OBSTETKK  s. 

have  to  look  for  the  cause  of  this  curious  and  objectionable  phenome- 
non, for  which  Johnson  alone  has  so  far  suggested  a  useful  purpose. 
Where  the  cause  does  exist,  we  do  not  know ;  but  it  is  quite  certain,  that, 
as  it  continues  for  months,  in  some  cases,  after  the  removal  of  both  ova- 
ries, it  can  not  be  in  those  glands.  Nor  is  it  in  the  uterus;  for  in  three 
cases  in  which  I  have  removed  the  uterus,  as  completely  as  it  can  be 
done,  menstruation  has  persisted  ever  since — in  one  of  them  for  nearly 
seven  years.  Removal  of  the  ovaries  alone,  is  followed  by  immediate 
and  complete  arrest  of  menstruation  in  about  fifty  per  cent,  of  the 
cases.  Removal  of  both  tubes,  with  or  without  the  ovaries,  is  followed 
by  the  same  arrest  in  about  ninety  per  cent,  of  the  cases;  and  I  suppose 
that  in  hysterectomy  the  arrest  occurs  in  at  least  ninety-seven  per  cent. 
But  it  is  the  exceptions,  in  such  a  case  as  this,  which  prove  the  rule; 
and  I  suppose  that  we  shall  some  day  find  a  special  nerve  mechanism 
which  is  the  real  cause  and  governor  of  the  phenomena  of  menstrua- 
tion ;  and  this  is  certain  to  be  ganglionic ;  for  a  ganglionic  system  gov- 
erns all  other  rythmic  phenomena." 

As  to  the  source  of  the  menstrual  discharge,  strange  and  varied  the- 
ories have  been  advanced.  The  most  recent  is  that  of  Dr.  A.  W.  John- 
stone,  to  which  Mr.  Tait  calls  attention  in  his  work  on  Diseases  of 
Women  and  Abdominal  Surgery — viz:  that  it  depends  on  the  action  of 
a  special  nerve,  which  lies  in  the  broad  ligament,  in  the  angle  between 
the  tube  and  round  ligament,  close  to  the  uterus.  Some  claim  it  has 
its  origin  in  the  cervix  and  os  uteri;  others  in  the  vagina,  tubes  and 
ovaries. 

Coste  believed  it  to  be  a  transudation  through  the  walls  of  the  cap- 
illary vessels  of  the  uterus,  being  chiefly  venous.  Dr.  Farre  advances 
the  theory,  that  there  may  be  permanent  vascular  orifices  through  which 
the  blood  escapes  during  the  menstrual  period;  that  these  orifices  are 
closed  during  the  inter-menstrual  period,  by  the  contractility  of  the 
tissue  surrounding  them. 

Pouchet  claimed,  that  the  greatest  part  of  the  mucous  membrane  is 
shed  at  each  menstrual  period ;  its  separation  from  the  uterine  walls 
involved  a  rupture  of  vessels,  and  thus  the  menstrual  flow.  The  most 
reasonable  theory,  however,  is,  that  the  tubes  are  the  starting  point  of 
the  catamenial  discharge;  that  the  epithelial  lining  and  a  portion  of 
the  uterine  mucous  add  to  the  detritus,  the  blood  being  largely  from 
the  uterine  walls,  the  result  of  a  process  of  diapedesis.  A  case  of 
chronic  inversion  of  the  uterus  was  recently  reported  before  the  Cin- 
cinnati Eclectic  Medical  Society,  in  which  this  condition  was  clearly 


MENSTRUATION OVULATION CONCEPTION.  105 

illustrated.  Menstruation  has  occurred  regularly  for  many  years;  at 
each  period  the  mucous  surfiace  of  the  inverted  uterus  is  bathed  in 
blood,  prior  to  which  many  drops  of  blood,  giving  it  a  beaded  appear- 
ance, are  noticeable;  also  the  loosening  and  casting  off  of  small  shreds 
of  the  epidermis — the  cause  of  the  hemorrhage. 

The  fact  of  menstruation  occurring  after  the  removal  of  the  uterus 
and  its  appendages,  may  be  due  "to  segments  of  the  organs  left  at  the 
pedicle,  either  in  hysterectomy  or  oophorectomy,  or,  perhaps,  to  the 
existence  of  a  supernumerary  ovary. 

Since  the  female  among  the  lower  animals  will  not  cohabit  with  the 
male  at  any  period  other  than  the  rutting  season,  it  would  indicate  that 
the  oestrus  and  ovulation  are  concurrent.  I  am  aware,  that  doubts  are 
entertained  by  some,  as  to  whether  the  oestrus  and  human  menstrua- 
tion are  analogous;  however,  admitting  that  they  are,  this  would  not 
be  positive  proof  but  that  ovulation  may  exist  irregularly  and  inde- 
dendently  of  the  rut. 

By  ovulation,  is  understood  the  functional  action  of  the  ovaries:  at 
which  time  occurs  the  escape  of  the  ovum  from  the  ovisac,  from  whence 
it  is  either  received  by  the  Fallopian  tube  and  transmitted  to  the  uterus, 
or  is  lost  in  the  peritoneal  cavity.  The  fluid  contents  of  the  ovisac 
gradually  increase  with  its  development,  until,  at  the  time  of  complete 
maturation,  the  distention  is  so  marked  that  rupture  is  the  result,  fol- 
lowed by  the  dehiscence  of  the  ovum.  The  functional  relation  ex- 
isting between  the  oviduct  and  the  ovary,  and  the  exact  manner  by 
which  the  ovum,  as  it  escapes  from  the  ovisac,  finds  lodgment  in  the 
oviduct  through  its  fimbriated  extremity — morsus  diaboli — and  is  then 
conveyed  to  the  uterus,  does  not  appear  to  be  clearly  defined.  Numer- 
ous opinions  have  been  advanced  as  the  subject  has  been  studied  and 
investigated.  Lusk,  in  his  Science  and  Art  of  Midwifery,  speaks  as 
follows,  on  the  MIGRATION  OF  THE  OVUM  : 

"  The  number  of  ova  in  each  ovary  has  been  estimated  by  Henle  at 
thirty-six  thousand.  Only  a  small  proportion  of  them,  however,  meet 
with  the  conditions  requisite  for  fruition.  It  is  probable,  that  many 
ova  perish  while  still  surrounded  by  the  stroma  of  the  ovary.  The 
history  of  extra-uterine  pregnancies  teaches  us  that,  in  some  instances 
at  least,  the  ovum,  after  its  discharge  from  the  Graafiau  follicle,  escapes 
into  the  abdominal  cavity.  It,  therefore,  becomes  an  interesting  subject 
of  inquiry  as  to  the  conditions  which  ordinarily  determine  the  passage 
of  the  ovum  from  the  ovary  into  the  Fallopian  tube  of  the  correspond- 
ing side.  It  will  not  do  to  assume,  as  is  usual,  a  peculiar  erectility  of 


106  KING'S  ECLECTIC  OBSTETRICS. 

the  Fallopian  tube,  which  enables  it  to  apply  its  funnel-shaped  extrem- 
ity to  the  ovary  just  at  the  moment  of  the  rupture  of  the  Graafian 
follicle.  Setting  aside  the  inherent  improbability  of  the  existence  of 
such  a  degree  of  intelligence  in  the  fimbrire  as  would  lead  to  the  exact 
adaptation  of  the  tube  to  the  precise  point  at  which  the  ovum  is  to  be 
discharged,  it  has  been  proved  that  the  Fallopian  tube  possesses  none 
of  the  characteristics  of  erectile  tissue.  Injections  of  its  vessels  after 
death  do  not  communicate  to  it  the  slightest  change  of  form  or  place. 

"  Muscular  action  has  also  been  often  invoked  to  explain  the  assumed 
manner  in  which  the  fimbrise  seize  the  ovary;  but  galvanization  of  the 
tubes,  practiced  upon  criminals  recently  executed,  produces  only  ver- 
micular contractions,  which  do  not  affect  the  position  of  the  fimbrise. 
Indeed,  wThen  we  remember  the  position  of  the  Fallopian  tubes  in  the 
pelvis,  and  bear  in  mind  that  they  are  at  all  times  necessarily  subjected 
to  the  pressure  of  the  intestines,  it  becomes  difficult  to  understand  how 
they  can  execute  any  very  extended  movements. 

"  In  the  absence  of  direct  experimental  proof,  the  suggestion  of 
Henle,  that  the  passage  of  the  ovum  into  the  Fallopian  tube  is  due  to 
currents  produced  in  the  serum  by  the  ciliated  epithelium,  which  cov- 
ers both  the  external  and  internal  surfaces  of  the  fimbrise,  is,  on  the 
score  of  probability,  entitled  to  the  most  consideration.  One  of  the 
fimbrise  (fimbria  ovarica)  is  permanently  attached  to  the  lower  angle 
of  the  ovary.  . 

"It  is  likely  that  the  ovum,  discharged  from  a  Graafian  follicle,  is 
floated  down  by  the  peritoneal  serum  toward  the  lower  and  outer  border 
of  the  ovary,  where  a  sufficient  current  is  present  to  insure  its  being 
caught  up  and  conveyed  into  the  infundibulum  tubse.  Failures  on  the 
part  of  the  ovum  to  reach  its  destination  are,  in  all  probability,  not 
uncommon.  Support  is  given  to  the  theory  of  the  importance  of  the 
cilia?  in  influencing  the  migration  of  the  ovum  by  the  observation  of 
Thiry,  that  in  batrachians,  which  have  the  oviducts  fixed  to  the  ab- 
dominal walls,  and  situated  at  a  distance  from  the  ovary ;  during  the 
rutting  period  little  pathways  of  ciliated  epithelium  form  in  the  peri- 
tonaeum, which  collectively  converge  toward  the  openings  of  the  tubes. 

"While  the  ovum  remains  in  tlie  ampulla,  or  dilated  portion  of  the 
tube,  its  further  progress  is  at  first  dependent  upon  the  movements  of 
the  cilia? ;  but,  after  the  isthmus  is  reached,  an  additional  propelling 
force  is  furnished  by  the  circular  muscular  fibers,  which  possess  a  peri- 
staltic action." 

The  attention  of  physiologists  has  recently  been  called  to  an  adenoid 


MENSTRUATION OVULATION — CONCEPTION.  107 

/unction  of  the  endometrium  and  subjacent  tissue.  The  cited  evidence 
of  secretory  power,  in  the  lining  of  the  uterus,  is  based  on  the  develop- 
ment of  the  decidual  structure,  which  is  always  evolved  as  soon  as 
pregnancy  occurs,  and  which  not  infrequently  developed  during  nor- 
mal menstruation.  Such  a  membrane,  or  vascular  meshwork,  may  be 
exuded  during  ovulation — the  low  grade  of  structure  not  depending 
upon  either  menstruation  or  pregnancy.  The  decidual  exudate  de- 
pends upon  exalted  vascular  activity  in  the  endometrium,  and  not 
upon  any  secretory  function.  In  fact,  a  membrane  or  vascular  texture 
can  not  be  secreted  any  more  than  a  tongue  or  an  ear  can  be  the  result 
of  adenoid  action. 

It  has  been  assumed  and  asserted  by  speculative  physiologists,  that 
during  inter-menstrual  periods  there  is  evolved  from  the  endometrium 
a  membranous  meshwork,  which  is  to  entrap  or  ensnare  the  fertilized 
ovum  when  it  emerges  from  the  Fallopian  conduit.  If  the  ovum  be 
not  fructified,  it  is  not  prevented  from  traversing  the  uterine  cavity, 
and  falling  into  the  vagina.  In  other  words,  the  speculative  net-work 
developed  from  the  endometrium  is  to  be  discriminative — is  to  let  the 
unfecundated  ovum  pass  the  barrier,  but  to  entrap  and  ensnare  the 
fertilized  body.  However,  to  get  rid  of  discriminating  power  ascribed 
to  ,the  deciduous  membrane,  the  meshwrork  is  to  entangle  the  unim- 
pregnated  egg  and  take  it  out  of  the  womb,  but  is  to  arrest  the  out- 
ward course  of  the  fertilized  ovum.  An  objectionable  feature  of  the 
scheme  is,  that  the  inter-menstrual  meshwork  is  to  be  denominated 
nidus,  a  nest,  and  the  entrapping  is  called  nidation,  or  nesting,  after 
the  manner  of  birds;  when  in  fact  the  uterine  exudate  is  more  a  net 
than  a  nest.  The  endometrium  does  secrete  mucus  by  means  of  crypts 
and  follicles  in  its  free  surface,  and  contributes  to  the  exudative  forma- 
tion of  the  decidual  structure,  but  it  does  not  develop  anything  in 
health  except  uterine  mucus,  which,  in  some  respects — in  odor,  for 
instance — is  peculiar.  In  a  normal  condition — between  menstrual  ac- 
tivities— the  endometrium  secretes  or  throws  off  endothelium,  as  the 
mucous  lining  of  the  mouth  does,  or  any  other  localized  portion  of  a 
mucous  structure. 

The  mucous  secretions  differ  to  an  appreciable  extent.  The  secre- 
tions of  the  urethra  differ  from  those  of  the  bladder  and  ureters.  The 
free  surface  of  the  endometrium  is  pale  and  smooth,  except  when  men- 
strual epochs  are  approached;  the  structure  then  attains  a  pinkish 
flush  of  vascularity,  and  at  length  becomes  so  congested  that  corpus- 
cles of  blood  burst  through  the  alternated  walls  of  the  vascular  capil- 


108  KING'S  ECLECTIC  OBSTETRICS. 

larics.  The  corpuscles  mix  with  mucus  and  exuded  lymph,  making  a 
fluid  which  is  decidedly  sanguineous,  but  is  never  pure  blood  unless  a 
hemorrhage  occurs. 

Toward  the  end  of  a  catamenial  nisus,  there  is  little  blood  and  much 
plastic  lymph  exuded,  as  in  ordinary  trumatism,  and  then  the  decidual 
exudate  or  meshwork  is  elaborated.  "Lining  the  fundus  of  the  womb 
as  it  does,  it  can  not  help  ensnaring  the  ovum  as  it  leaves  the  salpin- 
giau  canals,  whether  the  egg  be  impregnated  or  not.  If  the  ovum  be 
not  fertilized,  it  passes  off  with  the  detached  decidua;  and  if  it  be 
fructified,  the  pregnant  state  excites  uterine  vascularity,  and  secures 
the  services  of  the,  decidual  membrane  in  fixing  and  nourishing  the 
developing  ovum.  The  neoplastic  membrane  makes  no  discrimination 
between  the  unimpregnated  and  the  fertilized  egg,  but  the  condition 
of  pregnancy  enforces  the  kind  of  action  which  is  to  result  in  a  loss 
of  the  structure,  or  in  the  utilization  of  its  possible  offices  in  the  nutri- 
tion of  the  ovum.  It  has  been  suggested,  that  the  decidual  exudate  of 
menstruation  occludes  the  canal  of  the  uterine  cervix,  producing  me- 
chanical obstruction — membranous  dysmenorrhoaa ;  but  as  catamenial 
pains  are  mostly  over  before  the  menstrual  exudate  is  shed  or  cast  off, 
the  theory  has  few  substantial  facts  to  sustain  it.  The  womb  in  a  state 
of  physiological  hypertrophy — pregnancy — is  augmented  in  weight 
from  ounces  to  pounds.  Yet,  in  the  enlarged  state  it  is  increased 
mostly  in  muscular  evolution;  after  parturition,  the  organs  enter  upon 
rapid  involution,  so  that  in  a  few  weeks  it  returns  to  normal  weight 
and  size.  In  the  manifestation  of  these  great  changes,  there  is  no  dis- 
play of  increased  glandular  action  or  adenoid  activity. 

The  endometrium  undergoes  important  transformations,  yet  does 
not  become  appreciably  glandular  or  adenoid.  In  ectopic  gestation  a 
decidual  exudate  is  always  found  upon  the  free  surface  of  the  endo- 
metrium, as  if  ready  to  ensnare  the  fertilized  ovum,  but  the  function 
of  the  membrane  is  not  forced  into  use. 


DEVELOPMENT    OF    THE    HUMAN    OVUM.  109 

CHAPTER    XIV. 

DEVELOPMENT  OF  THE  HUMAN  OVUM. 

IT  will  now  be  proper  to  notice  those  changes  which  occur,  during 
pregnancy,  in  the  ovum,  as  it  progresses  in  its  development.  Shortly 
after  conception,  a  layer  of  coagulable  lymph  lines  the  whole  internal 
surface  of  the  uterus,  which  is  at  first  of  a  soft,  gelatinous  nature,  but 
which  soon  becomes  imperfectly  organized,  vascular,  and  of  a  reddish 
color ;  it  is  called  the  membrana  caduea  (caducous  membrane),  or 
membrana  decidua  (deciduous  membrane).  Several  other  names  have 
been  applied  to  it,  as  epichorion  by  Chaussier,  epione  by  Dutrochet, 
perione  by  Breschet,  anhistous  membrane  by  Velpeau,  adventitious 
lamina  by  de  Blainville,  nidal  decidua  by  Aveling,  etc.  This  mem- 
brane is  about  one  line  in  thickness,  and  is  in  contact  with  the  whole 
of  the  inner  uterine  surface  ;  its  inner,  or  fetal  surface  is  smooth  and 
polished,  with  striae  and  depressions  which  lead  into  canals,  bearing 
some  resemblance  to  that  of  serous  membranes,  and  its  external  or 
uterine  surface  is  rough  and  unequal,  and  closely  adheres  to  the 
internal  surface  of  the  uterus.  It  is  not  persistent  in  its  character, 
as  it  is  formed  only  during  conception,  or  as  stated  under  nidation, 
in  the  preceding  chapter;  and  it  is  expelled  with  the  ovum  and  its 
membranes  whenever  this  occurs.  Within  this  membrane  is  a  space 
or  cavity  called  the  cavity  of  the  decidua,  which  is  filled  with  a  limpid, 
serous  fluid,  to  which  M.  Breschet  has  given  the  name  hydroperion. 
This  fluid  is  present  simultaneously  with  the  caducous  membrane, 
or  perhaps  with  the  impregnation  of  the  ovum,  increases  in  quantity 
as  the  uterus  enlarges,  and  continues  to  be  secreted,  according  to 
Breschet,  until  the  caduea  vera  and  caduea  reflexa  come  in  contact 
with  each  other,  or  toward  the  fourth  month  ;  it  is  supposed  that  this 
liquid  aifords  nourishment  to  the  embryo  during  the  early  months, 
before  a  direct  placental  communication  is  established  between  it  and 
its  mother. 

The  manner  by  which  the  ovum  becomes  enveloped  in  this  mem- 
brane is  supposed  to  be  as  follows:  having  passed  through  the  Fal- 
lopian tube,  until  it  arrives  at  its  uterine  orifice,  it  pushes  before 
it  a  portion  of  the  membrana  caduea,  until  the  whole  ovum  is  sur- 
rounded and  inclosed  by  this  membrane  (F.  Fig.  25).  The  por- 


110 


KING'S  ECLECTIC  OBSTETRICS 


A.  The  cavity  of  the  uterine 
Neck- 


Fallopian  Tubes. 

C.  External,    or  Uterine  Ca- 

duca. 

D.  Cavity  of  the  Decidua. 

E  E.  Angles  at  which  the  De- 


tion  of  membrane  thus  covering  the  ovum,  is 
called  the  decidua  ovuli,  or  reflexa  (ovuline,  or 
reflected  decidua),  while  that  in  contact  with'the 
uterine  walls,  is  termed  the  decidua  uteri,  or  vera 
(uterine,  or  true  decidua).  As  the  ovum  grows, 
the  decidua  reflexa  approaches  nearer  and  nearer 
to  the  decidua  vera,  the  cavity  of  the  decidua 
diminishes,  until,  finally,  at  the  third  month  the 
cavity  is  obliterated,  and  the  two  decidua,  coming 
in  contact,  become  agglutinated  into  one  mem- 
brane. The  ovum,  it  will  be  seen,  is  not  com- 
pletely surrounded  by  the  decidua  reflexa,  and  at 
THE  CADUCA,  AFTER  that  part  of  the  uterus  from  which  this  membrane 
was  detached  by  the  advancing  ovum,  the  surface 
is  lined  by  no  membrane  whatever.  At  this  un- 
covered point  a  new  structure  is  developed  be- 
tween it  and  the  ovum,  bearing  some  resemblance 
to  the  membrana  decidua,  and  which  is  called 
decidua  serotina,  and  here  the  subsequent  forma- 

igies  at  wnicn  me  i»e-     ,  •  n    ,->  i  ,     i  i  rr*i_ 

cidua  vera  is  reflected  tion  of  the  placenta  takes  place.     The  uses  of 
by  the  advance  of  the  the  membrana  caduca,  are,  according  to  Moreau, 

F.  chorion.  "  to  prevent  the  ovum  from  floating  loosely  in  the 

G.  Amnios.  cavity  of  the   uterus ;  to  maintain  it  in  contact 
with  a  fixed  point  of  the  parietes  of  this  organ,  until  it  has  contracted 
sufficiently  numerous  and  firm  attachments  to  enable  the  embryo,  after 
being  developed  during  the  first  stages  of  pregnancy  at  the  expense 
of  the  surrounding  fluids,  to  extract  from  the  blood  of  the  mother, 
the  materials  suitable  for  its  nutrition  and  subsequent  growth ;  to.  de- 
termine the  place  of  insertion,  form,  and  extent  of  the  placenta ;  to 
prevent  superfetation ;  and,  according  to  Lobstein,  to  transmit  to  the 
chorion  and  amnion  the  vessels  which  furnish  these  membranes  with 
the  elements  of  nutrition  and  exhalation." 

The  above  is  the  description  generally  given  by  authors  relative  to 
the  caducous  membrane;  still,  it  is  not  a  settled  question,  and  much 
diversity  of  opinion  prevails  in  regard  to  it.  Some  consider  it  to  be 
a  secretion,  or  exhalation  from  the  internal  mucous  coat  of  the  uterus, 
effected  by  the  peculiar  excitement  resulting  from  conception  ;  while 
others  view  it  as  an  exfoliation  of  this  mucous  coat,  itself,  which,  from 
a  similar  cause,  has  undergone  considerable  changes  in  its  consistence 
and  vascularity.  The  former  is  the  most  commonly  received  opinion, 
and,  probably,  the  most  correct  one ;  it  maintains,  that  the  excitement 


DEVELOPMENT   OF    THE    HUMAN  OVUM.  Ill 

caused  by  a  fruitful  coition  occasions  the  secretion  of  a  plastic  lymph, 
\vhich  coagulates  and  forms  a  kind  of  false  membrane  or  caduca,  anal- 
ogous to  those  produced  on  inflamed  surfaces  by  the  exhalation  and 
coagulation  of  an  albuminous  fluid,  and  which  is  entirely  distinct  from 
the  mucous  membrane,  although  it  adheres,  more  or  less  firmly;  to  the 
latter  by  numerous  vascular  villi,  or  prolongations,  which  frequently 
*  extend  into  the  canal  of  the  cervix,  or  Fallopian  tubes.  When  the 
adhesion  of  this  false  membrane  is  but  slight,  the  ovum,  upon  entering 
the  uterine  cavity,  instead  of  pushing  forward  a  decidua  reflexa  at  the 
orifice  of  the  tube,  may  slip  between  the  caduca  and  uterus,  and  form 
an  attachment  at  some  other  point,  thus  giving  rise  to  the  various  pla- 
cental  insertions  which  are  met  with  in  practice. 

The  opposite  opinion  maintains  that  the  utricular  glands  of  the 
uterus  become  elongated,  augmented  in  size,  and  contorted,  their  se- 
cretion increases,  the  vessels  of  the  mucous  membrane  become  more 
fully  developed  in  size  and  number,  and  a  substance  composed  of 
nucleated  cells  fills  up  the  interfollicular  spaces  in  which  the  blood- 
vessels are  contained.  These  changes  produce  a  thickening  and  soft- 
ening of  the  mucous  membrane  itself,  with  increased  vascularity,  thus 
forming  the  deciduous  membrane.  But,  as  Prof.  Meigs  observes,  "  I 
can  not  readily  comprehend  how,  after  all  this  structure  is  once  thrown 
off  as  a  decidua,  it  can  ever  be  reproduced  for  the  service  of  subse- 
quent pregnancies."  Dr.  Carpenter  inquires,  if  the  views  relative  to 
the  mucous  membrane  of.  the  uterus  being  the  decidua,  are  well- 
founded,  how  are  we  to  explain  the  formation  of  the  decidua  continu- 
ously over  the  upper  orifice  of  the  cervix  uteri,  and  over  the  orifices 
of  the  Fallopian  tubes,  as  is  frequently,  though  not  always,  the  case  ? 

Again,  it  has  been  asserted  by  Dr.  Lee,  that  this  membrane  is  not 
formed  unless  the  ovum  reaches  the  uterus,  but  in  this  he  is  evi- 
dently in  error,  as  there  are,  at  least  to  my  mind,  a  sufficient  num- 
ber of  facts  recorded  to  prove  its  presence  independent  of  the 
arrival  of  the  ovum  at  the  uterus.  And,  if  I  am  not  mistaken,  Prof. 
Meigs,  as  well  as  other  investigators,  have  observed  the  decidua  in 
cases  of  extra-uterine  pregnancy.  Moreau  states,  that  "  it  is  even  found 
in  cases  of  tubular  and  ovarian  pregnancy,  provided  the  pregnancy  be 
not  too  far  advanced,  and  have  not  exceeded  five  or  six  months,  for 
we  are  inclined  to  believe  that  it  disappears  at  a  later  period."  Vel- 
peau  denies  that  the  membrane  is  organized,  hence,  he  has  called  it 
anhistous;  but  there  are  sufficient  proofs  of  its  organization,  as,  for 
Jnstance,  its  vascularity;  it  has  also  been  injected  by  Ruysch,  Burns, 


112  KING'S  ECLECTIC  OBSTETRICS. 

Lobsteiri,  and  others — beside,  it  is  liable  to  disease,  and  toward  the 
last  becomes  very  thin,  like  serous  or  cellular  tissue. 

Hunter  asserted  that  the  deciduous  membrane  had  three  openings, 
one  at  the  inner  orifice  of  the  cervix,  and  one  at  each  orifice  of  the 
Fallopian  tubes ;  were  this  the  case,  no  decidua  reflexa  would  be  formed, 
but  the  ovum  in  entering  the  uterus,  would  at  once  pass  through  the 
opening  into  the  cavity  of  the  decidua,  from  whence  it  could  escape 
out  of  the  uterus  through  the  opening  at  the  inner  orifice  of  the  cer- 
vix, and  no  conception  would  result.  Such  openings  in  the  membrane 
may  occasionally  be  present,  but  according  to  the  investigations  of 
many  excellent  observers  they  do  not  occur  as  a  general  rule.  It  has* 
also  been  denied  that  the  decidua  reflexa  is  a  mere  reflected  portion  of 
the  decidua  vera,  as  the  texture  of  the  two  are  said  to  be  non-identical ; 
and  that  the  reflexa  is  probably  formed  by  the  agency  of  nucleated 
cells  from  the  plastic  materials  thrown  out  from  the  decidua  vera,  in 
the  same  manner  as  the  chorion  is  supposed  to  be  formed  in  the  Fal- 
lopian tube,  from  similar  materials  secreted  from  its  lining  membrane. 
More  recently  it  has  been  advanced  that  the  decidua  is  formed  inde- 
pendently of  impregnation  (see  Nictation) ;  that  it  consists  of  two  dis- 
tinct layers,  one,  lining  the  wall  of  the  uterine  cavity,  and  termed,  the 
decidua  vera,  d.  uteri,  or  parietal  decidua,  the  external  surface  of  which 
presents  numerous  filaments,  while  its  internal  surface  is  smooth, 
shining,  but  presenting  numerous  elevations.  The  other,  forms  the 
inner  layer,  is  named  the  decidua  reflexa,  d.  ovuli,  d.  chorii,  and  pre- 
sents similar  elements  as  the  preceding,  its  internal  surface  being 
studded  with  numerous  pits,  probably  for  the  reception  of  the  villi  of 
the  chorion.* 


*From  recent  investigations  by  Dr.  Kundrat,  of  Vienna  (Rokistansky's  senior  As- 
sistant), and  which  are  published  in  the  Medizinische  Jahrbiicher,  1873,  No.  2,  and 
described  in  the  Medical  Times  and  Gazette,  Aug.,  1873,  it  appears  that  the  generally 
accepted  description  of  the  human  Impregnated  uterus  and  embryo,  is  only  partially 
correct.  The  purport  of  his  observations  are:  The  mucous  membrane  (mucosa) 
of  the  recently  gravid  uterus  is  known  as  the  decidua,  and  which  has  been  commonly 
divided  into  a  decidua  vera,  d.  reflexa,  and  d.  serotina;  at  first,  its  structure  bears  some 
resemblance  to  the  uterine  mucosa,  in  or  before  menstruation  ;  it  is  thickened,  the 
ghmds  are  dilated,  elongated,  and  tortuous,  and  there  is  a  great  increase  of  intertubular 
cells.  In  every  respect  the  structure  of  the  three  portions  of  the  decidua  is  very 
similar.  Inferiorly  the  d.  vera  abruptly  terminates  in  an  overhanging  border  at  a 
short  distance  from  the  cervix,  this  last  taking  no  part  in  the  formation  of  the  fetai 
cavity.  During  the  entire  period  of  pregnancy,  the  Fallopian  tubes,  as  well  as  theii 
inferior  openings,  are  patent.  Kundrat  farther  observes  that  when  the  impregnated 
ovum  reaches  the  inferior  tubal  opening,  its  progress  is  not  obstructed  by  an  adhesive 
growth  of  the  opposite  mucous  surfaces  to  each  other,  as  some  investigators  believe 


DEVELOPMENT   OF    THE    HUMAN    OVUM.  113 

From  this  brief  review  of  the  subject,  it  will  be  seen  that  it  is  still 
involved  in  obscurity,  and  those  who  desire  further  information  re- 
garding it,  are  referred  to  the  various  essays  by  Hunter,  Lee,  Chaus- 

for  no  such  adhesion  exists.  For  the  same  reason  the  ovum  does  not  push  before  it 
and  invaginate  a  portion  of  the  nmcosa,  which  becomes  the  decidua  reflexa.  The 
latter  is  clearly  an  outgrown  and  infolded  portion  of  the  decidua  vera,  possessing 
glands  on  its  deep  or  ovular  surface,  as  well  as  on  its  free.  The  ovum  is  retained  at 
the  fundus  of  the  uterus  by  the  swollen  decidua.  If  the  swelling  is  not  very  great, 
the  ovum  may  travel  down  toward  the  cervix;  and  it  is  for  this  reason  that  placenta 
przevia  is  more  common  among  multiparae.  He  does  not  believe  that  the  ovum  enters 
the  mouth  of  a  gland,  but  that  it  develops  on  the  irregular  surface  of  the  d.  serotina. 
As  pregnancy  advances  the  uterus  enlarges,  and  the  connection  between  it  and  the 
ovum  becomes  more  intimate  and  complex.  At  first  the  enlargement  of  the  uterus  is 
out  of  proportion  to  the  growth  of  the  embryo,  and  a  free  cavity  exists  between  the  d. 
vera  and  the  d.  reflexa,  which  is  filled  with  a  somewhat  opaque  mucoid  fluid.  The 
embryo  does  not  fill  the  uterine  cavity  until  the  fourth  month,  and  the  walls,  which 
were  previously  disproportionately  thick,  become  disproportionately  thin,  while  the 
envelopes  become  transparent.  In  the  fifth  month  the  process  has  advanced  still  an- 
other step,  by  the  adhesion — partial  at  least — of  the  opposite  walls  of  the  uterine 
cavity  ;  that  is,  of  the  d.  vera  and  the  d.  reflexa. 

As  regards  the  connection  between  the  chorion  and  the  decidua,  it  has  frequently 
been  stated  that  the  processes  or  villi  of  the  former  pass  into  the  glands  of  the  latter. 
Kundrat  remarks  that  this  arrangement  was  "but  seldom"  to  be  discovered.  On  the 
contrary,  the  chorion-villi  were  found  to  be  fixed  in  the  grooves  of  the  d.  serotina  and 
on  the  sides  of  its  elevations  by  a  connective  mass  composed  of  mucus  and  degener- 
ated epithelium.  Other  villi  had  buried  themselves  in  the  tissue  of  the  d.  serotina, 
and  formed  a  connection  so  intimate  that  any  attempt  at  separation  ended  in  rupture. 
It  is  here  that,  the  placenta  is  afterward  developed.  As  gestation  proceeds  the  changes 
of  the  decidua  are  very  considerable,  and  in  the  last  months  peculiarly  interesting. 
The  d.  reflexa  becomes  attenuated  by  pressure  until  reduced  to  a  simple  layer  of  the 
transparent  envelopes  of  the  embryo,  of  which  it  forms  the  most  external  portion.  On 
the  other  .hand,  the  d.  vera  and  the  d.  serotina  remain  as  comparatively  thick  layers 
of  tissue,  compact  and  cellular  on  the  surface,  but  spongy  in  their  deep  portion  from 
the  presence  of  the  numerous  ends  of  the  dilated  glands,  which  represent  sinuses 
lined  by  epithelium.  As  the  termination  of  pregnancy  approaches  there  occurs  a  re- 
markable change  on  the  lining  membranes  of  the  uterus.  These,  as  well  as  the  d. 
reflexa,  become  whitish,  dull,  and  of  a  pale  yellowish  or  even  yellowish-gray  tint, 
opacity  replaces  transparency,  and  the  process,  which  is  discovered  by  the  microscope 
to  be  one  of  fatty  degeneration,  passes  into  the  deeper  layers.  This  description,  of 
course,  reminds  us  of  t'he  simultaneous  fatty  degeneration  of  the  placenta.  When  par- 
turition occurs,  a  portion  of  the  membranes  is  expelled  with  the  fetus,  and  it  is  inter- 
esting to  inquire  what  part,  if  any,  of  the  envelopes  is  retained.  Careful  examination 
certainly  reveals  that  the  superficial  portion  of  the  decidua  vera  is,  as  a  rule,  in- 
cluded in  the  fetal  membranes,  while  the  deeper  portion  is  retained,  although  this  is 
not  always  the  case.  During  the  first  week  post-partum  the  discolored  lining  mem- 
brane of  the  uterus  may  be  found,  under  the  microscope,  to  present  the  characters  of 
the  decidua  vera,  but  the  sinuses  are  full  of  blood,  the  superficial  cellular  layer  gone, 
the  fatty  degeneration  extends  to  the  deepest  layers,  and  the  tissue  generally  is  infil- 
trated with  round  cells  and  blood.  The  lochial  discharge  consists  of  such  cells  and 

8 


114  KING'S  ECLECTIC  OBSTETRICS. 

sier,  Breschet,  Velpeau,  Cams,  Granville,  M.  Coste,  Weber,  Sharpey, 
Farre,  Priestley,  Barry,  etc. 

At  the  period  of  full  development  of  the  ovule,  it  escapes  from  the 
vesicle  inclosing  it,  and  passes  into  the  Fallopian  tube  through  the 
agency  of  the  fimbriated  extremity  of 'this  organ,  gradually  traversing 
its  canal  until  it  arrives  at  the  uterine  cavity.  The  modifications  un- 
dergone by  the  human  ovule  in  its  passage  through  the  Fallopian 
tube,  are  unknown,  but  are  supposed  to  be  similar  to  those  which 
occur  in  the  eggs  of  mammiferous  animals,  particularly  those  of  the 
rabbit  and  dog.  In  these  animals,  the  first  change  which  has  been 
observed  in  the  ovule  after  its  escape  from  the  ovary,  is  the  entire  dis- 
appearance of  both  the  germinal  vesicle  and  germinal  spot,  while  at 
the  same  time  there  will  be  found  a  collection  of  granules  in  the  cen- 
tral portion  of  the  ovum.  During  its  travel  through  the  first  half  of 
the  oviduct,  the  vitelline  membrane  becomes  somewhat  thickened, 
while  a  layer  of  the  granulations  which  formed  the  proligerous  disk 
of  the  ovule  previous  to  its  departure  from  the  ovary,  surrounds  the 
ovum,  but  which  disappears  as  it  traverses  the  second  half  of  the 
oviduct,  having  a  layer  of  a  transparent,  gelatinous  substance  to  occupy 
its  place  around  the  vitelline  membrane,  and  which  albuminous  layer, 
as  well  as  the  thickening  of  the  vitelline  membrane,  continues  to  in- 
crease. While  these  changes  are  being  effected,  the  yelk  gradually 
increases  in  density,  forming  a  compact,  homogeneous  mass — a  trans- 
parent fluid  occupying  the  space  existing  between  it  and  the  interior 
surface  of  the  vitelline  membrane ;  finally,  the  yelk  separates  into  two 
regular  spherical  divisions ;  these  again  separate,  forming  four  spheres, 
and  this  separation  continues,  until  from  the  numerous  small  spherical 
divisions  which  are  thereby  formed,  the  yelk  presents  a  mulberry  or 
raspberry  appearance.  These  spheres  or  granulations  decompose  as 
the  ovum  advances  toward  the  cavity  of  the  uterus,  and  finally  disap- 
pear, being  replaced  by  a  clear  and  transparent  fluid.  They  are  sup- 
posed to  condense  on  the  inner  wall  of  the  vesicle,  forming  there  a 
second  vesicle  which  has  been  called  the  blastodermic  or  umbilical 
vesicle  or  membrane,  or  germinal  membrane  or  area.  As  this  blastoderm 

of  products  of  disintegration.  In  the  second  week  post-partum  the  process  has  still 
farther  advanced,  and  the  epithelium  of  the  exposed  sinuses  is  found  to  be  prolifer- 
ating. Restitution  now  begins  and  advances,  and  soon  there  is  found  on  the  surface  of 
the  muscular  coat  a  fine  layer  of  connective  tissue,  covered  by  epithelium  and  fur- 
nished with  young  glands,  to  represent  the  mucosa  of  the  uterus,  which  is  again  at 
rest. 


DEVELOPMENT    OF    THE    HUMAN    OVUM.  115 

becomes  developed  after  the  arrival  of  the  ovum  in  the  uterus,  the 
albuminous  layer  surrounding  the  vitelline  membrane  disappears, 
while  this  membrane  diminishes  in  thickness.  About  the  sixteenth  or 
seventeenth  day  will  be  observed  a  rounded,  whitish  spot,  at  some 
point  of  the  blastodermic  vesicle,  standing  oat  apparently  detached, 
and  wrhich  is  named  the  embryonic  spot,  tache  embryonnaire,  or  area 
germinativa ;  it  is  composed  the  same  as  the  blastoderm,  of  cellular 
granulations,  and  from  it  commences  the  gradual  development  of  the 
embryo.  The  blastoderm  is  composecj  of  two  laminae,  the  external 
animal,  or  serous  layer,  and  the  internal,  mucous,  or  vegetative  layer,  the 
former  of  which  is  supposed  to  give  origin  to  the  brain  and  spinal 
cord,  organs  of  sense,  cartilage,  bones,  skin,  and  muscles,  or  organs  of 
animal  life;  and  the  latter  to  the  lungs,  liver,  spleen,  and  digestive 
tube,  or  organs  of  nutrition.  A  third  layer  has  also  been  recognized 
by  some  investigators,  which  is  situated  between  the  two  just  named; 
it  is  called  the  middle  or  vascular  layer,  ancj  is  supposed  to  assist  in 
the  development  of  the  heart,  circulatory  apparatus,  etc.  The  time 
required  for  the  passage  of  the  human  ovum  from  the  ovary  to 
the  uterus  is  supposed  to  be  from  eight  to  ten  or  twelve  days, 
and  it  is  about  this  latter  period,  the  twelfth  day  of  pregnancy, 
that  we  can  distinctly  observe  the  embryo,  which  then  appears  to 
be  a  mere  amorphous  vesicle,  measuring  about  three  lines,  while 
the  entire  ovum  measures  six  or  seven  lines.  The  envelopes  of 
the  ovum  are  three,  the  CHORION,  TUNICA  MEDIA,  or  MIDDLE 
MEMBRANE,  and  the  AMNION;  and  its  accessories  are  four,  the  UM- 
BILICAL VESICLE,  the  ALLANTOIS,  the  PLACENTA,  and  the  UMBIL- 
ICAL CORD. 

The  CHORION  is  a  thin,  glistening,  transparent  membrane,  very 
analogous  to  serous  tissues,  quite  resisting  for  its  tenuity,  and  forms 
the  external  covering  of  the  ovum,  passing  also  over  the  fetal  surface 
of  the  placenta  and  the  external  face  of  the  umbilical  cord,  and  may 
be  considered  as  corresponding  to  the  internal  lining  membrane  of  an 
eggshell.  It  is  formed  by  the  union  of  the  vitelline  membrane  with 
the  albuminous  envelope  which  this  acquires  while  in  the  oviduct; 
however,  this  is  still  a  question  among  physiologists,  some  of  whom 
suppose  it  to  be  formed  by  the  external  layer  of  the  blastodermic 
vesicle  and  the  allantois.  It  has  two  surfaces,  an  inner  or  fetal  sur- 
face, and  an  external  or  uterine  surface.  Both  of  these  surfaces  are 
smooth  at  first,  but  at  an  early  period,  about  the  second  week  of  preg- 
nancy, the  external  surface  presents  minute  granulations,  which  rapidly 


110  KING'S  ECLECTIC  OBSTETRICS. 

augment  in  length,  forming  numerous  villi  or  velvety  prolongations 
with  which  the  chorion  soon  becomes  covered,  and  which  penetrate 
into  the  decidua,  preventing  the  ovum  from  injuriously  moving  about. 
These  spongy,  cylindrical  villi  disappear  from  the  general  surface 
about  the  second  or  third  month,  but  at  the  spot  where  the  chorion 
comes  in  contact  with  the  uterus,  and  where  the  secondary  caduca  or 
decidua  serotina  is  formed,  they  enlarge  and  become  vascular,  giving 
origin  to  the  placenta.  The  vascularity  of  the  chorion  does  not  man- 
ifest itself  until  after  the  development  of  the  allantois,  about  the 
second  month,  when  it  consists  of  two  layers  or  laminae,  the  external 
or  primitive  one  of  which  is  non-vascular,  and  is  called  the  exochorion  ; 
while  the  other,  the  internal  or  allantoid  layer,  is  highly  vascular,  and 
is  named  endochorion. 

In  the  early  period  of  pregnancy  the  chorion  is  separated  from  the 
amnion  by  an  albuminous  layer,  which  condenses  into  a  thin  web-like 
membrane  termed  tunica  media;  and  this  albuminous  fluid  is  more 
abundant  in  the  first  weeks  of  gestation.  In  the  midst  of  this  fluid  is 
situated  the  umbilical  vesicle,  or  yelk-bag.  As  the  ovum  matures,  the 
external  face  of  the  chorion  unites  with  the  decidua  reflexa,  while  its 
inner  face  comes  in  contact  with  the  amnion  after  the  second  month ; 
there  have  been  instances,  however,  where  at  full  term,  a  considerable 
quantity  of  fluid  existed  between  the  amnion  and  chorion,  termed  false 
waters;  its  escape  has  given  rise  to  the  belief  that  the  liquor  amnii 
had  passed  off.  When  this  fluid  is  discharged  several  times  during 
one  pregnancy,  it  constitutes  hydrorrhea  (see  page  180).  The  chorion 
serves  to  envelope  and  protect  the  ovum  during  its  passage  from  the 
oviduct  to  the  uterus,  furnishes  a  sheath  for  the  umbilical  cord,  assists 
in  the  production  of  the  placenta,  and,  probably  through  the  attach- 
ment of  its  villi  to  the  decidua,  nourishment  is  absorbed  from  the 
maternal  blood  by  which  the  vitality  of  the  embryo  is  sustained ;  at 
the  parturient  period  it  assists,  in  connection  with  the  amnion,  to  form 
a  bag  containing  the  amniotic  liquor,  which  materially  promotes  the 
softening  and  dilatation  of  the  os  uteri. 

The  AMNION  is  the  most  internal  covering  of  the  embryo,  around 
which  it  forms  a  sac;  it  is  very  thin,  smooth,  and  transparent,  and 
is  more  dense  and  resisting  than  the  chorion,  which  it  very  much  re- 
sembles in  structure  and  appearance.  It  is  supposed  to  be  formed  by 
the  internal  lamina  of  the  fold  of  the  external  serous  layer  of  the 
blastoderm  around  the  embryo  (which  forms  the  cephalic  and  caudal 
hoods),  and  is  continuous  with  the  margins  of  the  ventral  opening  of 


DEVELOPMENT   OF   THE    HUMAN    OVUM.  117 

the  embryo;  however,  there  are  several  other  views  concerning  its 
origin.  Its  internal  surface  exhales  a  liquid  in  which  the  embryo 
floats  freely ;  its  external  surface  is  more  or  less  separated  from  the 
chorion,  the  space  between  them  being  filled  with  an  albuminous 
liquid.  It  apparently  consists  of  condensed  cellular  tissue,  in  which 
neither  blood-vessels  nor  nerves  have  yet  been  recognized.  As  the 
development  of  the  ovum  progresses,  the  space  between  the  amnion 
and  chorion  diminishes,  the  albuminous  fluid  found  between  them 
gradually  disappears,  until  finally  the  two  envelopes  come  in  contact 
and  adhere  to  each  other.  The  amnion  forms  the  outer  coat  of  the 
fetal  face  of  the  placenta,  and  of  the  cord ;  and  a  division  of  the  cord 
•shows  us  the  chorion  placed  between  the  cord  proper  and  the  amnion. 
Its  uses  are  to  furnish  the  liquor  amnii,  to  aid  in  forming  the  mem- 
branes, and  bag  of  waters,  and  to  serve  as  a  covering  to  the  umbilical 
cord,  the  liquor  amnii,  and  the  fetus. 

The  LIQUOR  AMNII,  also  known  as  the  amniotic  fluid,  waters  of 
the  amnios,  etc.,  is  a  fluid  contained  within  the  amnion,  and  in  which 
the  embryo  floats ;  by  some  it  is  supposed  to  be  an  exhalation  or 
secretion  from  the  amnion,  by  others  to  be  a  product  of  the  fetus,  and 
'  by  others  again  to  be  a  secretion  from  both  the  fetus  and  its  parent. 
The  probability  is,  that  the  liquor  amnii  proper  is  exhaled  by  the 
internal  surface  of  the  membranes  of  the  ovum,  the  elements  of  which 
are  furnished  by  the  uterine  vessels,  and  that  it  may  be  mixed  or 
adulterated  with  the  fetal  excretions,  especially  at  an  advanced  period 
of  pregnancy.  This  fluid  varies  in  quantity  as  well  as  in  its  proper^ 
ties ;  during  the  early  stage  of  gestation,  when  compared  with  the 
fetus,  it  is  proportionally  greater,  there  being  from  half  a  fluidrachm 
to  a  fluidrachm  present  when  the  embryo  can  hardly  be  seen  by  the 
naked  eye,  and  although  it  continues  to  increase  until  full  term,  yet 
its  relative  proportion  to  the  size  of  the  fetus  gradually  diminishes,  so 
that  at  parturition,  while  the  fetus  may  weigh  from  six  to  eight 
pounds,  the  quantity  of  fluid  will  seldom  be  found  to  exceed  a  pint. 
lu  some  few  cases  it  may  amount  to  quarts.  Its  appearance  varies 
from  that  of  a  transparent  and  limpid  fluid,  more  commonly  observed 
in  the  early  period  of  pregnancy,  to  that  of  a  thick,  slightly  yellow, 
green,  or  brown  color,  and  which  is  more  usual  to  the  advanced  stage. 
It  is  soft  and  viscous  to  the  touch,  has  a  specific  gravity  of  1.004,  and 
emits  an  odor  somewhat  resembling  that  of  semen,  though  occasion- 
ally, especially  when  the  fetus  is  dead,  this  odor  is  putrid  and  very 
offensive ;  its  taste  is  saltish.  Sometimes  it  becomes  milky  or  clouded, 


118  KING'S  ECLECTIC  OUST  ETHICS. 

and  frequently  contains  white  clots,  which  are  detached  pieces  of  the 
fetal  sebaceous  covering ;  greenish  or  dark-colored  flakes,  being  por- 
tions of  undiluted  meconium,  are  likewise  often  observed  in  it.  Its 
most  common  appearance  at  parturition  is  that  of  a  dingy  liquid,  hav- 
ing a  tinge  of  yellow  or  green.  Heat  renders  it  cloudy;  alcohol  or 
caustic  Potassa  causes  a  fleecy  precipitate,  with  which  nutgalls  form  a 
brownish  deposit,  similar  to  a  dilute  solution  of  gelatin ;  Nitrate  of 
Silver  occasions  an  abundant  white  precipitate,  which  is  insoluble  in 
Nitric  Acid ;  and  the  tincture  of  Violets  becomes  changed  to  green  by 
it.  Analysis  has  found  in  it  a  large  proportion  of  water,  with  albu- 
men, albuminate  of  soda,  chloride  of  sodium,  carbonate  of  soda,  phos- 
phate and  carbonate  of  lime,  urea,  and,  probably,  a  peculiar  free  acid, 
called  amnic  or  amniotic  acid.  Its  use  appears  to  be  to  protect  the 
embryo  from  any  severe  compression  of  the  uterine  walls ;  to  protect 
it  from  the  effects  of  falls  or  blows ;  to  prevent  any  adhesion  of  the 
fetus  while  in  utero,  and  allow  it  free  motion ;  to  protect  the  fetus, 
during  parturition,  from  the  injurious  effects  of  uterine  contraction 
upon  its  body,  until  all  its  parts  are  in  a  suitable  condition  to  permit 
its  expulsion ;  to  aid  in  the  dilatation  of  the  os  uteri,  at  term,  by  means 
of  the  bag  of  waters,  as  well  as  to  lubricate  the  parts  through  which 
the  fetus  has  to  pass,  thereby  facilitating  its  delivery.  Some  physi- 
ologists believe  that  it  likewise  aids  in  nourishing  the  fetus,  pre- 
vious to  the  formation  of  the  placenta  and  establishment  of  the  fetal 
circulation. 

.  The  UMBILICAL  VESICLE,  vesicula  umbilicus,  or  vesicula  alba, 
yelk-bag ;  is  formed  by  the  internal,  or  mucous  layer  of  the  blasto- 
derm ;  it  is  of  a  rounded,  or  pyriform  shape,  is  situated  in  the  space 
between  the  amnion  and  chorion,  and  communicates  by  a  long  pedicle, 
or  duct,  with  the  intestinal  tube,  upon  which  it  lies.  It  forms 
FIG.  26  .  a  sac,  seldom  larger  than  a  small  pea,  and 

contains  a  viscid,  transparent,  yellowish-white 
fluid,  in  which  may  be  seen  a  few  globules 
and  numerous  granules.  It  appears  to  be  com- 
posed of  an  external  or  vascular  layer,  and  an 
internal  or  mucous  layer.  The  following  account 
of  its  formation,  is  given  by  Prof.  Meigs : 
"When  the  blastoderm  has  partly  undergone 
the  morphological  -changes  that  convert  it  into 
SEGMENT  OF  THE  SPHERE  the  earliest  rudimental  embryon,  part  of  the  yelk 
OF  THE  VITELLUS.  corpuscles  still  remained  unappropriated ;  and  as 


DEVELOPMENT    OF   THE    HUMAN    OVUM. 


119 


they  are  still  contained  in  their  original  vitel- 
line  membrane,  they  constitute  a  small  but 
visible  ball,  called  the  umbilical  vesicle. 
Originally,  the  vitellus  was  a  sphere,  of 
which  Fig.  26  represents  a  segment.  The 
blastoderm  is  developed  upon  a  segment  of  (\  I 
this  sphere  as  at  A,  in  Fig.  27.  When  the 
blastoderm  doubles  or  folds  its  edges  in- 
ward, it  pinches  (or  contracts)  a  portion  of 

the  vitellary  ball,  as  in  Fig.  28.     In  a  still  „ 

*  BLASTODERM  DEVELOPED  UP- 

further  progress,  as  shown  by    Fig.  29,  the      ON  THE  SEGMENT  OF  THE 
portion  of  the  vitellary  ball  that  remains  out-      SPHERE  OF  THE  VITELLTJS. 
side  of  the  embryon  is  connected  to  the  embryo  by  a  delicate  tube,  or 
vitellary  duct."     Velpeau  states,  that  this  duct  opens  into  the  fetal 
ilium;  Rigby,  Ludlow,  and  Oker,  consider  FIG.  28. 

the   appendicula   vermiformis   as   the    re- 
mains of  it.     As  pregnancy  advances,  the 
yelk  having  been  transformed,  the  umbilical 
vesicle  becomes  atrophied,  and  the  develop- 
ment of  the  amnion  removes  it  further  and 
further  from  the  embryo,  at  the  same  time 
elongating  its  duct  or  pedicle,  the  canal  of 
which  remains  open  till  the  sixth  or. eighth 
week  of  gestation,  after  which  it  is  obliter-       INWARD  FOLDING  OF  THE 
ated,  and  the  umbilical  vesicle  becomes  flat-    EDGES  OF  THE  BLASTODERM. 
tened,  diminished,  of  a  lenticular  shape  and  gradually  fused  into  the  cord, 
and  entirely  disappears  after  the  third  or  fourth  month ;  in  a  few  rare 
cases,  it  has  been  found  at  full  F 

term.  Its  use  is  supposed  to 
be  to  afford  nourishment  to 
the  embryo,  until  its  pla- 
cental  connection  with  the 
mother  is  established. 

The  external  or  vascular 
layer  of  the  umbilical  vesicle 
has  ramifying  over  its  pari- 
eties  two  blood-vessels,  an 
artery,  and  a  vein,  which  are 
called  the  omphalo-mesenteric,  or  vitello  mesenteric  vessels,  and  which  ac- 
company the  pedicle,  forming  a  part  of  it.  The  omphalo-mesenteric 
artery  arises  from  the  aorta,  and  as  it  reaches  the  summit  of  the  intestinal 


FURTHER  PROGRESS  OF  THE  BLASTODERM. 


120 


KING'S    ECLECTIC    OBSTETRICS. 


convolutions,  it  gives  off  branches  to  the  mesentery  and  to  the  intestine ; 
then  it  extends  to  the  pedicle,  through  which  it  passes  until  it  reaches 
the  umbilical  vesicle,  upon  which  it  is  distributed.  In  the  adult,  that 
part  which  supplies  the  mesentery  is  converted  into  a  mesenteric  artery, 
all  the  rest  being  obliterated,  as  the  umbilical  vesicle  disappears.  The 
omphalo-mesenteric  vein,  enters  the  abdomen,  passes  around  the  duode- 
num, and  opens  into  the  umbilical  vein  just  as  this  is  emerging  from 
the  liver.  In  its  passage  around  the  duodenum  it  gives  off  branches 
to  the  stomach  and  intestines,  and  when  it  empties  into  the  umbilical 
vein,  it  sends  a  large  trunk  to  the  liver;  the  whole  disappears  with 
the  vesicle  and  its  pedicle,  except  that  portion  which  furnishes  the 

above  branches,  which  remains 
in  the  adult  as  the  ventral,  or 
hepatic-portal  vein.  Profes- 
sor Meigs  admirably  illustrates 
the  arrangement  of  the  om- 
phalo-mesenteric vessels,  and 
cord,  by  the  following  dia- 
gram, Fig.  30 :  "  Let  A  A,  be 
a  portion  of  the  abdomen  of 
the  embryo,  and  c  c,  the  na- 
vel, or  umbilical  ring;  B  B, 
the  navel  string,  or  cord,  laid 
open ;  D,  the  umbilical  vein, 
bringing  back  the  blood  from 
the  placenta,  and  passing  into 
the  belly  at  the  ring,  to  go  to 
the  liver;  E,  F,  the  two  um- 
bilical arteries  of  the  fetus ; 
H,  the  umbilical  vesicle,  or 
vitelline  sac,  whose  pipe,  con- 
duit, or  efferent-duct  runs 
along  the  umbilical  cord  to  the  navel,  and  passing  into  the  belly 
empties  itself  into  the  ilium,  G  G,  which  bends  up  to  receive  the  dis- 
charge ;  K,  L,  represents  the  omphalo-mesenteric  vessels." 

The  ALLANTOIS,  or  attantoid  vesicle,  is  a  small  sac,  or  bladder, 
which  may  be  observed  about  the  tenth  day,  and  which  arises  from  the 
inferior  part  of  the  intestinal  canal,  or  caudal  extremity  of  the  embryo ; 
it  is  found  near  the  umbilical  vesicle,  between  the  chorion  and  amnion  ; 
its  growth  is  rapid,  and  soon  becomes  attached,  by  its  base,  to  the 


DIAGRAM  OF  THE    OMPHALO-MESENTRIC 

VESSELS. 


DEVELOPMENT   OF   THE    HUMAN   OVUM.  121 

inner  surface  of  the  chorion.  On  the  parietes  of  the  allantois  are  dis- 
tributed the  terminal  branches  of  the  two  umbilical  arteries  and  vein. 
The  uraehus,  or  pedicle  of  the  allantois,  is  a  cord,  which  is  pervious  in 
early  embryonic  life,  and  which  passes  out  of  the  fetal  body  at  the 
navel,  being  accompanied  by  the  umbilical  blood-vessels  to  the  chorion, 
which  they  pierce,  sending  branches  into  its  villi,  which  increase  in 
size  as  these  villi  form  the  placental  connection  with  the  uterus. 

The  allantois  rapidly  disappears,  so  that  in  a  few  days  after  its  ap- 
pearance there  can  be  observed  only  a  cord  of  greater  or  less  length, 
passing  from  the  embryo  to  the  chorion,  and  containing  the  umbilical 
vessels  within  it ;  this  cord,  likewise,  gradually  becomes  lost  in  the  sub- 
stance of  the  umbilical  cord,  only  a  portion  of  it  remaining  within  the 
abdomen  of  the  embryo,  to  form  the  uraehus,  at  the  rectal  termination 
of  which  is  subsequently  formed  the  urinary  bladder.  In  consequence 
of  this  early  disappearance  of  the  allantois,  many  physiologists  have 
denied  its  existence.  The  use  of  this  vesicle,  or  membrane,  is  to  con- 
duct blood  from  the  embryo  to  the  chorion,  or,  as  remarked  by  Prof. 
Meigs,  "  the  allantois  may  be  said  to  be  a  bladder,  or  vesicle,  upon 
which  the  umbilical  arteries  climb  toward  the  wall  of  the  womb,  to 
attach  themselves  there."  It  is,  likewise,  stated  to  receive  the  urine 
of  the  fetus,  secreted  in  early  uterine  life.  Dr.  Carpenter  makes  the 
following  remarks  in  relation  to  this  vesicle : 

"  With  the  evolution  of  a  circulatory  apparatus,  adapted  to  absorb 
nourishment  from  the  store  prepared  for  the  use  of  the  embryo,  and  to 
convey  it  to  its  different  tissues,  it  becomes  necessary  that  a  respira- 
tory apparatus  should  also  be  provided,  for  unloading  the  blood  of  the 
carbonic  acid,  with  which  it  becomes  charged  during  the  course  of  its 
circulation.  The  temporary  respiratory  apparatus,  now  to  be  described, 
bears  a  strong  resemblance  in  its  own  character,  and  -especially  in  its 
vascular  connections,  with  the  gills  of  the  mollusca;  which  are  pro- 
longations of  the  external  surface  (usually  near  the  termination  of  the 
intestinal  canal),  and  which  almost  invariably  receive  their  vessels  from 
that  part  of  the  system.  This  apparatus  is  termed  the  allantois.  It 
consists  at  first  of  a  kind  of  diverticulum,  or  prolongation,  of  the  lower 
part  of  the  digestive  cavity,  the  formation  of  which  has  been  already 
described.  This  is  at  first  seen  as  a  single  vesicle,  of  no  great  size; 
and  in  the  fetus  of  mammalia,  which  is  soon  provided  with* other 
means  of  aerating  its  blood,  it  seldom  attains  any  considerable  dimen- 
sions. In  birds,  however,  it  becomes  so  large  as  to  extend  itself 
around  the  whole  yelk-sac,  intervening  between  it  and  the  membrane 
of  the  shell;  and  through  the  latter  it  conies  into  relation  with  the 


122 


KING'S    ECLECTIC    OBSTETRICS. 


external  air.     The  diagram  (Fig.  31),  will  serve  to  explain  its  origin 
and  position  in  the  human  ovum.     The  chief  office  of  the  allantois,  in 

FIG.  31. 

E,         GI          F 


DIAGRAM  o?  THE  HUMAN  OVUM   AT  THE  TIME  OF  THE 
FORMATION  OF  THE  PLACENTA. 

A.  Muco-gelatinous  substance  blockiug  up  the  Oi  Uteri. 

B  B.  Fallopian  Tubes. 

C  C.  Pecidua  Vera,  at  2  C,  prolonged  into  the  Fallopian  Tube. 

D.  Cavity  of  the  Uterus,  almost  completely  occupied  by  the  Ovum. 

E  E.  Angles  at  which  the  Decidua  Vera  is  reflected. 

F.  Decidua  Serotina. 

G.  Allantois. 

H.  Umbilical  Vesicle. 

I.   Arnnios. 

K.  Chorion,  with  the  outer  fold  of  Serous  Tunic. 

mammalia,  is  to  convey  the  vessels  of  the  embryo  to  the  chorion ;  and 
its  extent  bears  a  pretty  close  correspondence  with  the  extent  of  sur- 
face, through  which  the  chorion  comes  into  vascular  connection  with 
the  decidua.  Thus,  in  the  carnivora,  whose  placenta  extends  like  a 
band  around  the  whole  ovum,  the  allantois  also  lines  the  whole  inner 
surface  of  the  chorion,  except  where  the  umbilical  vesicle  comes  in 
contact  with  it.  On  the  other  hand,  in  man  and  the  quadrumana, 


DEVELOPMENT    OF    THE    HUMAN    OVUM.  123 

whose  placenta  is  restricted  to  one  spot,  the  allantois  is  small,  and  con- 
veys the  fetal  vessels  to  one  portion  only  of  the  chorion.  When  these 
vessels  have  reached  the  chorion,  they  ramify  in  its  substance,  and 
send  filaments  into  its  villi ;  and  in  proportion  as  these  villi  form  that 
connection  with  the  uterine  structure,  which  has  been  already  de- 
scribed, do  the  vessels  increase  in  size.  They  then  pass  directly  from 
the  fetus  to  the  chorion,  and  the  allantois  being  no  longer  of  any  use, 
shrivels  up,  and  remains  as  a  minute  vesicle,  only  to  be  detected  by 
careful  examination.  The  same  thing  happens  in  regard  to  the  um- 
bilical vesicle,  from  which  the  entire  contents  have  been  by  this  time 
exhausted ;  and  from  henceforth  the  fetus  is  entirely  dependent  for 
the  materials  of  its  growth,  upon  the  supply  it  receives  through  the 
placenta,  which  is  conducted  to  it  by  the  vessels  of  the  umbilical  cord. 
This  state  of  things  is  represented  in  the  diagram  (Fig.  31).  The  al- 
lantois has  a  correspondence  in  situation  with  the  urinary  bladder ;  but 
it  is  only  the  lower  part  of  it  pinched  off,  as  it  were,  from  the  rest, 
that  remains  as  such.  The  duct  by  which  it  is  connected  with  the  ab- 
domen gradually  shrivels ;  and  a  vestige  of  this  is  permanent,  forming 
the  urachus,  or  suspensory  ligament  of  the  bladder,  by  which  it  is  con- 
nected with  the  umbilicus.  Before  this  takes  place,  however,  the  al- 
lantois is  the  receptacle  for  the  secretion  of  the  corpora  wolffiana,  and 
of  the  true  kidneys,  when  they  are  formed." 

The  PLACENTA,  or  afterbirth,  is  a  soft,  spongy,  vascular  mass, 
occupying  about  one-third  of  the  external  covering  of  the  ovum,  and 
forming  the  principal  connection  between  the  embryo  and  the  uterus. 
It  is  a  flattened,  irregularly  circular  body,  of  a  more  or  less  intense 
reddish-gray  color,  varying  in  diameter  from  six  to  nine  inches,  some- 
times having  one  diameter  longer  than  the  others,  about  an  inch  in 
thickness  at  its  point  of  junction  with  the  umbilical  cord,  from  which 
it  gradually  tapers  off  toward  the  circumference,  which  seldom  exceeds 
two  or  three  lines,  and  weighing  one  or  two  pounds,  depending, 
however,  upon  its  size  and  the  amount  of  blood  it  contains.  It  most 
usually  has  the  umbilical  cord  inserted  at  its  center ;  occasionally  this 
passes  into  it,  at  or  near  the  circumference,  and  with  this  disposition 
the  vessels  of  the  cord  will  frequently  be  found  to  separate  into 
numerous  branches  before  they  reach  the  substance  of  the  placenta ; 
this  is  termed  the  battledore  placenta.  The  placenta,  umbilical  cord, 
and  membranes,  are  collectively  called  the  secundines. 

The  placenta  presents  two  surfaces,  an  external  or  uterine,  and  an 
internal  or  fetal.  The  fetal  surface  has  a  smooth,  polished  appearance, 


124  KING'S    ECLECTIC    OBSTETRICS. 

and  is  marked  by  the  numerous  radiations  of  the  vessels  of  the  umbili- 
cal cord,  forming  a  kind  of  network,  which  may  enable  us  to  dis- 
tinguish the  placenta  in  artificial  deliveries ;  this  surface  is  covered  by 
the  chorion  and  amnion,  the  former  of  which  intimately  adheres  to 
it,  and  sends  processes  between  the  lobules,  while  the  latter  is  loose 
and  nearest  the  fetus.  Each  one  of  the  umbilical  arteries  upon  reach- 
ing the  placental  surface  divides  into  two  branches,  and  this  dichoto- 
mous  division  is  repeated  until  these  vessels  have  diminished  in  size 
to  a  diameter  of  about  three-sixteenths  of  an  inch,  when  they  pass 
through  the  chorion  into  the  placental  tissue,  numerously  subdividing 
to  form  the  ultimate  villous  tufts  or  ramifications ;  the  blood  is  then 
conveyed  back  to  the  cord,  by  about  sixteen  veins,  which  run  on  the 
placental  surface  along  side  of  the  chief  branches  just  referred  to,  and 
terminate  in  the  one  vein  of  the  umbilical  cord.  The  uterine  surface, 
when  removed  from  the  uterine  wall,  presents  a  uniform,  but  not 
smooth  appearance,  and  is  slightly  convex;  it  has  a  fleshy  resemblance, 
and  is  divided  by  deep  sulci  or  furrows  into  numerous  irregularly 
shaped  lobes,  from  half  an  incli  to  about  an  inch  and  a  half  in 
diameter,  which  are  connected  with  each  other,  at  the  bottom  of  these 
sulci,  by  a  loose  cellular,  or,  according  to  Velpeau,  lamellated,  albumin- 
ous tissue,  which  is  easily  lacerated.  '  Upon  an  investigation,  it  will 
be  found  that  each  of  these  lobes  or  cotyledons,  is  formed  by  the  . 
ramifications  of  one  branch  of  the  umbilical  arteries  and  veins,  on 
their  first  separation,  and  that  the  vessels  of  one  lobe  do  not  anasto- 
mose with  those  of  another,  and  but  slightly  with  each  other.  This 
surface  is  not  in  direct  contact  with  the  uterine  wall,  but  is  separated 
from  it  by  the  interposition  of  the  decidua  serotina  or  placental  decidua, 
an  albuminous  layer  analogous  in  appearance  to  the  true  caducous 
membrane,  which  is  more  firmly  attached  to  the  placenta  than  to  the 
uterus,  and  which  enters  into  the  fissures  separating  the  lobes,  when 
not  too  deep,  in  which  latter  case  it  passes  from  one  lobe  to  another, 
forming  a  kind  of  membranous  bridge,  while  a  thick  partition  of 
cellulo-mucous  substance  penetrates  deeply  between  the  lobes.  The 
circumference  of  the  placenta  is  thin  and  irregular,  and  measures  from 
twenty-one  to  twenty-seven  inches ;  its  margin  is  continuous  with  the 
chorion,  and  is  contiguous  to  the  fold  formed  by  the  caduca  when 
passing  over  the  ovum  to  constitute  the  decidua  reflexa ;  between  this 
fold  and  the  placental  circumference  is  a  thickening  or  density  of 
substance,  so  disposed  for  the  reception  of  the  placental  border  as  to 
form  a  triangular  sinus. 

The  earliest   rudiments  of  the   placenta   are  observed  toward  the 


DEVELOPMENT    OF    THE    HUMAN    OVUM.  125 

termination  of  the  first  month  of  pregnancy,  which  become  gradually 
developed  until  the  third  month,  when  the  organ  acquires  its  proper 
character,  and  continues  to  increase  in  size  with  the  growth  of  the 
fetus.  As  soon  as  the  ovule  has  reached  the  uterus,  the  chorion  is 
observed  to  be  covered  with  numerous  villi  which  give  to  it  a  downy 
appearance,  but  those  villi  in  contact  with  the  decidua  reflexa,  proba- 
bly from  an  absence  of  proper  material  for  their  development,  become 
atrophied  and  filamentous,  serving  merely  as  points  of  union  between 
the  chorion  and  decidua;  while  those  which  are  exposed  to  the  uterine 
wall,  receiving  nourishment  from  the  exudation  of  lymph  which  takes 
place  on  the  surfaces  of  both  the  uterus  and  ovum,  continue  to 
develop  themselves,  elongate,  become  converted  into  vessels,  and 
ultimately  form  the  placental  part  of  the  placenta.  (Fig.  31.)  The 
uterine  portion  of  the  placenta  is  the  lymph  above  referred  to,  which 
forms  a  thin,  soft,  delicate  tissue  known  as  the  decidua  serotina,  and 
which  is  furnished  more  copiously  by  the  uterus,  on  account  of  the 
superior  size  and  vitality  of  this  organ  compared  with  those  of  the 
ovum.  At  that  portion  of  the  uterus  where  the  placenta  is  situated, 
will  be  found  large  cells  or  sinuses  which  communicate  freely  with 
each  other,  but  which  do  not  extend  beyond  the  decidua  serotina,  this 
membrane  answering  the  purpose  of  a  valve  to  prevent  the  blood  in 
them  from  passing  into  the  cavity  of  the  gravid  uterus;  these  cells  are 
the  uterine  sinuses,  and  into  them  the  blood  is  poured  by  the  curling 
uterine  arteries  terminating  in  a  capillary  extremity.  The  capillary 
vessels  of  the  fetus,  covered  by  the  thin  decidua,  insinuate  themselves 
into  these  sinuses,  and,  without  any  interference  of  the  circulation 
of  either  the  fetal  or  maternal  fluid,  the  change  is  here  effected  which 
probably  removes  the  effete  matter  of  the  fetal  blood,  while  at  the 
same  time  this  fluid  absorbs  oxygen  from  the  maternal  blood;  and 
these  changes  are  brought  about  without  the  existence  of  any  vascular 
intercommunication  between  the  mother  and  fetus,  the  action  some- 
what resembling  that  which  takes  place  in  the  lungs  of  an  adult, 
between  the  venous  blood  and  the  atmospheric  air — Weber,  Kolliker, 
Turner,  "Wincklen,  and  Delore,  have  demonstrated  that  the  maternal 
blood  does  circulate  in  the  placenta,  bathing  the  villosities  of  this 
formation.  And  Dr.  T.  Snow  Beck  affirms  that  uthe  cavernous 
structure  of  the  placenta  is  in  direct  communication  with  the  canals 
of  the  sinuses  or  veins,  and  that  these  vessels  carry  the  blood  away 
from  the  placenta,  which  is  brought  there  by  the  utero-placental 
arteries,"  and  that  there  "  is  no  such  thing  as  a  feeble  wall  or  delicate 


ll>||  KIN(.'s    K(   LKCTIC    OI5STETKK  S. 

membrane,  either  at  or  forming  the  line  of  separation,  nor,  indeed, 
structures  of  any  kind  that  prevent  the  flow  of  blood  direct  from  the 
placenta  into  the  uterine  sinuses  or  veins." 

The  placenta  may  attach  itself  to  any  part  of  the  internal  surface 
of  the  uterus,  more  commonly  at  or  near  the  orifice  of  one  of  the 
tubes,  occasionally  in  the  vicinity  toward  the  fundus,  rarely  toward 
the  neck,  and  still  more  seldom  over  the  inner  os  uteri;  this  latter 
position  is  termed  placenta  prcevia,  and  is  dangerous  to  both  mother 
and  child  on  account  of  the  hemorrhage  which  is  apt  to  ensue  as  it 
becomes  detached  from  the  uterine  wall,  during  labor,  by  the  dilata- 
tion of  the  os  uteri.  These  placental  situations  are  supposed  to  be 
determined  by  the  character  of  the  adhesion  existing  between  the 
caduca  and  uterine  wall,  as  to  firmness  as  well  as  to  the  degree  of 
resistance  afforded  by  the  caduca  to  the  advancing  ovule ;  thus,  if  the 
adhesion  be  weak  between  the  decidua  and  uterine  wall  at  the  utero- 
tubal  orifice,  the  ovule  may  slip  or  pass  down  between  them  until 
it  meets  with  sufficient  resistance  to  impede  its  further  progress,  and 
at  this  point,  where  it  is  stayed,  commences  the  formation  of  the 
decidua  reflexa,  as  well  as  of  the  placenta.  And  if  the  attachment 
be  so  slight  as  to  permit  the  fecundated  ovule  to  pass  out  of  the 
uterus  and  through  the  canal  of  the  cervix,  conception  does  not  take 
place.  It  must  be  borne  in  mind,  that  the  attachment  of  the  placenta 
is  by  apposition  only,  the  decidua  serotina  being  interposed  between 
it  and  the  uterine  wall;  and  when  actual  adhesion  occurs,  it  is  in- 
variably the  result  of  disease. 

In  cases  where  more  than  one  fetus  is  present,  we  generally  find  a 
separate  cord,  placenta,  and  set  of  membranes  for  each  one,  and  though 
the  placentae  may  be  joined  together,  forming  apparently  a  single  or- 
gan, yet  there  will  be  no  anastomosing  of  the  blood-vessels,  the  circu- 
lation of  each  child  being  perfectly  independent,  so  that  should  one 
die  or  become  diseased  in  utero,  the  other  may  continue  to  live  or  be 
healthy.  In  some  few  instances,  there  have  been  found  exceptions  to 
this — two  children  have  been  inclosed  in  one  bag  of  membranes,  or 
when  in  separate  ones,  there  has  been  a  communication  of  their  vas- 
cular systems. — The  use  of  the  placenta  is  to  form  the  principal  con- 
nection between  the  embryo  and  the  uterus  in  order  to  contribute  to 
the  nourishment  of  the  former.  (Fig.  31.) 

The  UMBILICAL  CORD,  funis  umbilicalis,  or  navel  string,  is  a 
long,  flexible,  and  vascular  cord  which  serves  as  a  connecting  medium 


DEVELOPMENT    OF    THE    HUMAN    OVUM.  127 

between  the  fetus  and  placenta.  It  has  two  insertions,  a  placental  and 
a  fetal.  The  placental  insertion  is  usually  in  the  center  of  the  placenta, 
though  it  may  occur  at  any  point  between  the  center  and  circumfer- 
ence of  this  organ ;  the  fetal  insertion  is  at  the  umbilicus.  At  birth, 
its  average  length  is  from  sixteen  to  twenty-four  inches,  though  it  fre- 
quently varies  from  this  measurement,  having  been  found  several  feet 
long,  and  again  only  six  or  seven  inches.  Its  thickness  is  likewise 
variable ;  ordinarily  it  is  about  equal  to  that  of  the  little  finger ;  when 
it  exceeds  this  it  is  termed  a  fat  cord,  and  when  it  is  smaller  it  is  called 
a  lean  cord.  This  variation  in  its  thickness  depends  upon  the  larger 
or  smaller  amount  of  a  viscid,  semi-transparent  fluid  which  is  infil- 
trated in  the  cellular  tissue  of  the  cord,  and  which  is  named  the  gela- 
tine of  Wharton;  this  fluid  is  coagulable  by  heat  and  acids,  and  when 
unequally  distributed  occasions  swellings  or  nodes  on  the  cord. 

During  the  early  weeks  of  pregnancy  the  umbilical  cord  does  not 
exist ;  its  first  appearance  is  about  the  end  of  the  first  month,  when 
the  embryo  is  fully  separated  from  the  blastodermic  vesicle,  at  which 
period  it  is  composed  of  the  duct  of  the  umbilical  vesicle,  urachus. 
omphalo-mesenteric  vessels,  and  a  covering  of  amnion  and  chorion. 
It  is  now  cylindrical,  thick  and  short,  but  elongates  in  proportion  as 
the  umbilical  vessel  removes  and  disappears.  At  about  the  commence- 
ment of  the  third  month,  the  umbilical  vesicle,  urachus,  and  omphalo- 
mesenteric  vessels  being  obliterated  and  amalgamated  with  the  cord ; 
this  now  consists  of  two  arteries,  one  vein,  fine  areolar  tissue,  gelatine 
of  Wharton,  and  an  external  covering  of  amnion  and  chorion,  which 
elements  remain  until  the  termination  of  pregnancy.  At  first  the  cord 
is  straight,  but  after  the  second  month,  a  torsion  of  the  vessels  com- 
mences, the  two  arteries  run  uniformly  and  spirally  ardund  the  vein, 
usually  in  a  direction  from  left  to  right ;  the  vein  thus  occupying  the 
axis  of  the  cord. 

The  vein  of  the  umbilical  cord  is  of  a  thickness  nearly,  if  not  quite 
equal,  to  that  of  the  two  arteries  combined ;  it  has  no  valves,  its  walls 
are  thin  but  firm,  and  it  performs  the  functions  of  an  artery,  carrying 
the  pure  and  vitalized  blood  from  the  placenta  to  the  fetus.  It  arises 
from  the  placenta ;  the  venous  ramifications  of  each  placental  lobe 
uniting  on  the  surface  of  the  placenta  to  form  the  cord,  which  passes 
onward  into  the  umbilical  ring  of  the  fetus,  where  it  separates  from 
the  two  arteries  and  proceeds  toward  the  liver. 

The  two  arteries  of  the  umbilical  cord  arise  from  the  fetal  internal 
iliacs,  of  which  they  are  branches,  and  proceed  toward  the  umbilicus, 


128  KING'S    ECLECTIC    OBSTETRICS. 

where  they  separate  and  traverse  the  vein  in  a  tortuous  manner  until 
they  reach  the  placenta,  into  which  they  give  off  numerous  ramifica- 
tions. The  walls  of  the  arteries  are  thick,  resisting,  and  contractile, 
and  they  pulsate  strongly.  The  arteries  perform  the  office  of  veins, 
as  they  convey  the  adulterated  blood  from  the  fetus  to  the  placenta. 
It  is  very  rarely  that  any  different  arrangement  of  the  cord  from  the 
above,  has  been  observed ;  a  few  instances  have  been  related  where  but 
one  artery  was  present,  and  Velpeau  has  stated  that  two  veins  have 
been  met  with.  The  colors  of  the  blood  in  the  vein  and  arteries  re- 
semble each  other  so  nearly  as  to  be  scarcely  distinguishable. 

The  cord  is  subject  to  abnormities  and  accidents,  as,  a  division  of 
the  vessels  before  having  reached  the  placenta,  a  varicose  or  hydatidic 
condition,  a  rupture  of  the  coats,  a  closure  of  the  vessels,  an  insertion 
into  some  other  part  of  the  fetus  than  the  umbilicus,  or  into  a  wrong 
part  of  the  decidua,  and  twists  or  knotsr ^especially  when  the  cord  is 
very  long,  which  interfere  more  or  less  with  the  circulation  and  con- 
sequent nutrition  of  the  fetus.  Any  of  these  conditions  may  occasion 
the  death  of  the  fetus,  and  abortion,  though,  some  of  them,  when 
slight,  exert  no  important  influence.  The  cord  is  most  commonly 
above  the  head  of  the  child,  yet  there  are  often  exceptions ;  it  has  been 
found  coiled  once  or  twice  around  the  child's  neck,  or  body,  or  a  limb, 
in  some  instances  causing  death  by  strangulation,  or  the  loss  of  a  limb ; 
occasionally,  it  is  found  presenting  before  the  fetal  head.  In  cases  of 
twins,  each  fetus  has  its  own  cord,  though  instances  have  been  met 
with  where  there  existed  a  communication  between  the  cords  of  the 
several  fetuses. 


CHAPTER    XV. 

OP    THE    FETUS    AND    ITS    DEVELOPMENT. 

THE  ovule,  or  ovum,  is  the  human  egg  previous  to  its  impregnation, 
though  these  terms  are  frequently  applied  to  the  embryo  and  the  fetus; 
as  long  as  this  is  amorphous  or  of  an  undetermined  form,  it  has  re- 
ceived the  name  of  germ;  from  the  period  when  a  definite  form  can  be 
observed  until  the  third  month,  it  is  called  the  embryo,  from  which 
time  until  its  expulsion  from  the  uterus,  the  term  fetus  is  applied  to  it. 


THE    FETUS    AND    ITS    DEVELOPMENT.  129 

After  birth  it  becomes  the  child  or  infant,  though  either  of  these  latter 
terms  are  often  used  synonymously  with  fetus. 

The  study    and  investigation  of  the  de-  FIG.  32. 

velopment  of  the. human  embryo  (Fig.  32), 
is  one  which  the  student  finds  attended 
with  considerable  difficulty ;  for,  notwith- 
standing the  many  discoveries  of  physiol- 
ogists on  this  point,  there  still  remain  much 
obscurity  and  uncertainty  attached  to  it,  as 
is  evident  from  the  various  views  which 
have  from  time  to  time  been  presented  to 
the  profession.  Dr.  Rigby,  in  his  work  on 

Midwifery,  has  probably,  given  the  clearest,       SECTION   OF  A  MORE    DE- 
and    at    the    same    time    the    most    concise  ^ELOPED  OVUM,  IN  WHICH 

.n  ,.  n.     ,1  i  3  i  THE     TWO      PORTIONS  —  THE 

illustration  ot    the    researches  and    conclu- 

EMBRYONIC   AND     UMBILICAL 

sions  of  those    who  have    investigated    the  VESICLE— BEGIN  TO  APPEAR. 
subject,  as  will  be  found  in  the  following  o.  umbilical  vesicle. 

,•  i  •    i  -n      T  I-    Internal    laydr  of   the   Blasto- 

(^uotation,   which    will,  I    trust,    prove    ac-  derma  ' 

ceptable  to  all  who  are  interested :  E-  External  layer. 

-,  -r-r     ,  mi  •  i  i         V.  Vitelline  Membrane. 

"Embryo. —  ihere  is,  perhaps,  no  de- 
partment of  physiology  which  has  been  so  remarkably  enriched  by 
recent  discoveries,  as  that  which  relates  to  the  primitive  development 
of  the  ovum  and  its  embryo.  The  researches  ot  Baer,  Rathke,  Pur- 
kinje,  Valentin,  etc.,  in  Germany;  of  Dutrochet,  Prevost,  Dumas, 
and  Coste,  etc.,  in  France;  and  of  Owen,  Sharpey,  Allen,  Thompson, 
Jones,  and  Martin  Barry,  in  England,  but  more  especially  those  of 
the  celebrated  Baer,  have  greatly  advanced  our  knowledge  of  the'se 
subjects,  and  led  us  deeply  into  those  mysterious  processes  of  nature 
which  relate  to  our  first  origin  and  formation. 

"  These  researches  have  all  tended  to  establish  one  great  law,  con- 
nected with  the  early  development  of  the  human  embryo,  and  that 
of  other  mammiferous  animals,  viz.:  that  it  at  first  possesses  a  struct- 
ure and  arrangement  analogous  to  that  of  animals  in  a  much  lower 
scale  of  formation ;  this  observation  also  applies,  of  course,  to  the 
ovum 'itself,  since  a  variety  of  changes  take  place  in  it  after  impreg- 
nation, before  a  trace  of  the  embryo  can  be  detected. 

"  At  the  earliest  periods,  the  human  ovum  bears  a  perfect  analogy 
to  the  eggs  of  fishes,  amphibia,  and  birds ;  and  it  is  only  by  carefully 
examining  the  changes  produced  by  impregnation  in  the  ova  of  these 
lower  classes  of  animals,  that  we  have  been  enabled  to  discover  them 
in  the  mammalia  and  human  subject. 
9 


130 


KING'S    ECLECTIC    OBSTETRICS. 


FIG.  33. 


SECTION  OF  A  HEN'S  EGO  WITHIN 


Periphery  of  the  Yelk. 

B.  Vesicle  of  Purkinje,  imbedded  in  the 

Cumulus. 

C.  Vitellary  Membrane. 

D.  Inner  and  Outer  Layers  of  the  Cap- 

sule of  the  Ovum. 

E.  Indusium  of  the  Ovary. 


"  As  the  bird's  egg,  from  its  size,  best 
affords  us  the  means  of  investigating 
these  changes,  and  as  in  all  essential 
respects  they  are  the  same  in  the  hu- 
man ovum,  it  will  be  necessary  for  us 
to  lay  before  our  readers  a  short  account 
of  its  structure  and  contents,  and  also 
of  the  changes  which  they  undergo, 
after  impregnation.  In  doing  this,  we 
shall  merely  confine  ourselves  to  the  de- 
scription of  what  is  applicable  to  the 
THEOVAR*.  human  ovum.  (.%.  33.) 

A..  The  Granular  Membrane  forming  the          "  The  6gg    IS    knOWU  to    Consist  of  twO 

distinct  parts,  the  vitellus  or  yelk  sur- 
rounded by  its  albumen  or  white;  to 
the  former  of  these  we  now  more  par- 
ticularly refer.  The  yelk  is  a  granular 
albuminous  fluid,  contained  in  a  granu- 
lar membranous  sac  (the  blastodermic  membrane),  which  is  covered  by 
an  investing  membrane  called  the  vitelline  membrane  or  yelk-bag.  The 
impregnated  vitellus  is  retained  in  its  capsule  in  the  ovary,  precisely 
as  the  ovum  of  the  mammifera  is  in  the  Graafian  vesicle.  The  whole 
ovary  in  this  case  has  a  clustered  appearance,  like  a  bunch  of  grapes, 
each  capsule  being  suspended  by  a  short  pedicle  of  indusium. 

"  In  those  ova  which  are  considerably  developed  before  impregna- 
tion, the  granular  blastodermic  membrane  is  observed  to  be  thicker, 
and.  the  granules  more  aggregated  at  that  part  which  corresponds  to 
the  pedicle,,  forming  a  slight  elevation  with  a  depression  in  its  center, 
like  the  cumulus  in  the  proligerous  disk  of  a  Graafian  vesicle.  This 
little  disk  is  the  blastoderma,  germinal  membrane,  or  cicatricula;  in 
the  central  depression  just  mentioned  is  an  exceedingly  minute  vesicle, 
first  noticed  by  Professor  Purkinje,  of  Breslau,  and  named  after  him ; 
FIQ.  34.  'n  more  correct  language,  it  is  the  germinal  ves- 

ick.     (Fig.  34.) 

"  According  to  Wagner,  the  germinal  vesicle 
is  not  surrounded  by  a  disk  before  impregnation ; 
and  it  is  only  after  this  process  that  the  above- 
mentioned  disk  of  granules  is  formed.  By  the 
time  the  ovum  is  about  to  quit  the  ovary,  the 
vesicle  itself  has  disappeared,  so  that  an  ovum 
has  never  been  found  in  the  oviduct  containing  a  germinal  vesicle, 


A.  Vitelline  Membrane. 

B.  Blastoderma. 

From  T.  W.  Jane*. 


THE    FETUS   AND    ITS    DEVELOPMENT.  131 

nothing  remaining  of  it  beyond  the  little  depression  in  the  cumulus 
of  the  cieatricula. 

"The  rupture  of  the  Purkinjean  or  germinal  vesicle  has  been  sup- 
posed by  Mr.  T.  "W.  Jones  to  take  place  before  impregnation ;  but  the 
observations  of  Professor  Valentin  seem  to  lead  to  the  inference  that 
it  is  a  result  of  that  process,  and  must  be  therefore  looked  upon  as 
one  of  the  earliest  changes  which  take  place  in  the  ovum  or  yelk-bag 
upon  quitting  the  ovary.* 

"  During  its  passage  through  the  oviduct  (what  in  mammalia  is  called 
.the  Fallopian  tube),  the  ovum  receives  a  thick  covering  of  albumen, 
and  as  it  descends  still  farther  along  the  canal  the  membrane  of  the 
shell  is  formed. 

"On  examining  the  appearance  of  the  ovum  in  mammiferous  ani- 
mals, and  especially  the  human  ovum,  it  will  be  found  that  it  presents 
a  form  and  structure  very  analogous  to  the  ova  just  described,  more 
especially  those  of  birds.  It  is  a  minute,  sphericle  sac,  filled  with  an 
albuminous  fluid,  lined  with  blastodermic  or  germinal  membrane,  in 
which  is  seated  the  germinal  vesicle  or  vesicle  of  Purkinje.  When 
the  ovum  has  quitted  the  ovary  the  germinal  vesicle  disappears,  and 
on  its  entering  the  Fallopian  tube  it  becomes  covered  with  a  gelatin- 
ous, or  rather  albuminous  covering.  This  was  inferred  by  Valentin, 
who  considered  that  ( the  enormous  swelling  of  the  ova,  and  their 
passage  through  the  Fallopian  tubes/  tended  to  prove  the  circum- 
stance. (Edin.  Med.  and  Surg.  Journal,  April,  1836.)  It  has  since 
been  demonstrated  by  Mr.  T.  W.  Jones,  in  a  rabbit  seven  days  after 
impregnation.  The  vitellary  membrane  seems,  at  this  time,  to  give 
way,  leaving  the  vitellus  of  the  ovum  merely  covered  by  its  spherical 
blastoderma,  and  incased  by  the  layer  of  albuminous  matter  which 
surrounds  it. 

"  From  what  we  have  now  stated,  a  close  analogy  will  appear  be- 
tween the  ova  of  the  mammalia  and  those  of  the  lower  classes,  more 
especially  birds,  which  from  their  size  afford  us  the  best  opportunities 
of  investigating  this  difficult  subject. 

"In  birds,  the  covering  of  the  vitellus  is  called  yelk-bag;  whereas, 
in  mammalia  and  man  it  receives  the  name  of  vesieula  umbilicalis. 
Its  albuminous  covering,  which  corresponds  to  the  white  and  mem- 
brane of  the  shell  in  birds,  is  called  chorion:  by  the  time  that  the 

*  We  said,  "  one  of  the  earliest  changes."  Mr.  Jones  considers  that  "  the  breaking 
up  of  the  surface  of  the  yelk  into  crystalline  forms,"  is  the  first  change  which  he  has 
observed. 


132 


KING'S    ECLECTIC   OBSTETRICS. 


ovum  IKIS  reached  the  uterus,  this  outer  membrane  has  undergone  a 
considerable  change;  it  becomes  covered  with  a  complete  down  of  little 
absorbing  fibril l;i\  which  rapidly  increase  in  size  as  development  ad- 
vances, until  it  presents  that  tufted,  vascular  appearance,  which  we 
have  already  mentioned  when  describing  this  membrane. 

"  The  first  or  primitive  trace  of  the  embryo  is  in  the  cicatricula  or 
germinal  membrane,  which  contained  the  germinal  vesicle  before  its 
disappearance.  In  the  center  of  this,  upon  its  upper  surface,  may  be 
discovered  a  small  dark  line:*  'this  line  or  primitive  trace  is  swollen 
at  one  extremity,  and  is  placed  in  the  direction  of  the  transverse  axis 
of  the  egg.'  (Fig.  35.) 

FJO.  35.  "As      development      ad- 

vances, the  cicatricula  ex- 
pands. ( We  are  indebted 
to  Pander/f  says  Dr.  Allen 
Thompson,  in  his  admirable 
essay,  above  quoted,  '  for 
the  important  discovery, 
that  toward  the  twelfth  or 
fourteenth  hour,  in  the  hen's 
egg  the  germinal  membrane 
becomes  divided  into  two 
layers  of  granules,  the  serous  and  mucous  layers  of  the  cicatricula ; 
and  that  the  rudimentary  trace  of  the  embryo,  which  has  at  this  time 
become  evident,  is  placed  in  the  substance  of  the  uppermost  or  serous 
layer.'  .  '  According  to  this  observer,  and  according  to  Baer,  the  part 
of  this  layer  which  surrounds  the  primitive  trace  soon  becomes  thicker; 
and  on  examining  this  part  with  care,  toward  the  eighteenth  hour,  we 
observe  that  a  furrow  has  been  formed  in  it,  in  the  bottom  of  which 
the  primitive  trace  is  situated;  about  the  twentieth  hour  this  furrow  is 
converted  into  a  canal  open  at  both  ends,  by  the  junction  of  its  mar- 
gins (the  plicce  primitives  of  Pander,  the  laminae,  dor  sales  of  Baer) :  the 
canal  soon  becomes  closed  at  the  cephalic  or  swollen  extremity  of  the 
primitive  trace,  at  which  part  it  is  of  a  pyriform  shape,  being  wider 
here  than  at  any  other  part.  According  to  Baer  and  Serres,  some 
time  after  the  canal  begins  to  close,  a  semi-fluid  matter  is  deposited  in 
it,  which  on  its  acquiring  greater  consistence,  becomes  the  rudiment  of 

•Allen  Thompson  on  the  Development  of  the  Vascular  System  in  the  Fetus  of  Ver- 
tebrated  Animals.  (Edin.  New  Philosoph.  Journal,  Oct.  1830.) 

t  Pander,  Beitragezur  Entwickelungs-geschichte  des  Hunchens  im  Eie.  Wurzburg, 
1817. 


A.  XiauspareiH  Area. 


15.  Primitive  Trace. 


THE    FETUS    AND    ITS    DEVELOPMENT. 


133' 


the  spinal  cord;  the  pyriform  extremity  or  head  is  soon  after  this  seen 
to  be  partially  subdivided  into  three  vesicles,  which  being  also  filled 
with  a  semi-fluid  matter,  gives  rise  to  the  rudimentary  state  of  the 
eucephalon.3  '  As  the  formation  of  the  spinal  canal  proceeds,  the  parts 
of  the  serous  layer  which  surround  it,  especially  toward  the  head,  be- 
come thicker  and  more  solid,  and  before  the  twenty-fourth  hour  we 
observe  on  each  side  of  this  canal  four  or  five  round  opaque  bodies ; 
these  bodies  indicate  the  first  formation  of  the  dorsal  vertebrae.  (Fig.  36.) 

FIG.  36. 


A.  Transparent  Area. 

B.  Lamina  Dorsales. 

C.  Cephalic  End. 

D.  Rudiments  of  Dorsal  Vertebrae. 

E.  Serous  Layer. 


F.  Lateral  Portion  of  the  Primitive  Trace. 

G.  Mucous  Layer. 
H.  Vascular  Layer. 

K.  Laminae  Dorsales  united  to  form  the  Spi- 
nal Canal. 


" '  About  the  same  time,  or  from  the  twentieth  to  the  twenty- 
fourth  hour,  the  inner  layer  of  the  germinal  membrane  undergoes 
a  farther  division,  and  by  a  peculiar  change  is  converted  into  the 
vascular  mucous  layers.'  (A.  Thompson,  op.  cit. )  It  will  thus 
be  seen,  that  the  germinal  membrane  is  that  part  of  the  ovum 
in  which  the  first  changes  produced  by  impregnation  are  observed. 
The  rudiments  of  the  osseous  and  nervous  systems  are  formed  by  the 
outer  or  serous  layers ;  the  outer  covering  of  the  fetus  or  integuments, 
including  the  amnios,  are  also  furnished  by  it.  'The  layer  next  in 
order,  has  been  called  vascular,  because  in  it  the  development  of  the 
principal  parts  of  the  vascular  system  appears  to  take  place.  The 
third,  called  the  mucous  layer,  situated  next  the  substance  of  the  yelk, 
is  generally  in  intimate  connection  with  the  vascular  layer,  and  it  is  to 


134 


KINGS    ECLECTIC    OUSTKTRICS. 


FIG.  37. 


A.  Serous  Layer. 
B  C.  Vascular  Layer. 


D.  Mucous  Layer. 

E.  Heart. 


the  changes  which  these  combined  layers  undergo,  that  the  intestinal, 
the  respiratory,  and  probably  also  the  glandular  systems,  owe  their 
origin.'  (A.  Thompson,  op.  dt.,  p.  298.  (Fig.  37.) 

"The  embryo  is  therefore 
formed  in  the  layers  of  the  ger- 
minal membrane,  and  becomes 
as  it  were,  spread  out  upon  the 
surface  of  the  ovum:  the 
changes  which  the  ovum  of 
mammalia  undergoes  appear, 
from  actual  observation,  to  be 
precisely  analogous  to  those 
in  the  inferior  animals. 
{Boer,  Prevost,  and  Dumas.)  From  the  primitive  trace,  which 
was  at  first  merely  a  line  crossing  the  cicatricula,  and  which  now 
begins,  rapidly  to  exhibit  the  characters  of  the  spinal  column,  the 
parietes  of  the  head  and  trunk  gradually  approach  farther  and  farther 
toward  the  anterior  surface  of  the  abdomen  and  head  until  they  unite ; 
in  this  way  the  sides  of  the  jaws  close  in  the  median  line  of  the  face, 
occasionally  leaving  the  union  incomplete,  and  thus  appearing  10  pro- 
duce in  some  cases  the  congenital  defects  of  hair  lip  and  cleft  palate. 
In  some  way  the  ribs  meet  at  the  sternum ;  and  it  may  be  supposed 
that  sometimes  this  bone  is  left  deficient,  and  thus  may  become  one  of 
the  causes  of  those  rare  cases  of  malformation,  where  the  child  has 
been  born  with  the  heart  external  to  the  parieties  of  the  thorax.  In 
like  manner  the  parietes  of  the  abdomen  and  pelvis  close  in  the  linea 
alb'a  and  symphysis  pubis,  occasionally  leaving  the  integuments  of  the 
navel  deficient,  or,  in  other  words,  producing  congenital  umbilical 
hernia,  or  at  the  pubes  a  non-union  of  its  symphysis  with  a  species  of 
inversion  of  the  bladder,  the  anterior  wall  of  that  viscus  being  nearly 
or  entirely  wanting. 

"  The  cavity  of  the  abdomen  is  therefore  at  first  open  to  the  vesicula 
umbilicalis  or  yelk,  but  this  changes  as  the  abdominal  parietes  begin 
to  close  in ;  in  man  and  the  mammalia  merely  a  part  of  it,  as  above 
mentioned,  forms  the  intestinal  canal,  whereas,  in  oviparous  animals, 
the  whole  of  the  yelk-bag  enters  the  abdominal  cavity,  and  serves  for 
an  early  nutriment  to  the  young  animal.  Another  change  connected 
with  the  serous  or  outer  layer  of  the  germinal  membrane  is  the  forma- 
tion of  the  amnion.  The  fetal  rudiment,  which  from  its  shape  has 
been  called  earina,  now  begins  to  be  enveloped  by  a  membrane  of  ex- 
ceeding tenuity,  forming  a  double  covering  upon  it;  the  one  which 


THE    FETUS    AND    ITS    DEVELOPMENT.  135 

immediately  invests  the  fetus  is  considered  to  form  the  future  epider- 
mis; the  other,  or  outer  fold,  forms  a  loose  sac  arpund  it,  containing 
the  liquor  amnii.  While  these  changes  are  taking  place  in  the  serous 
layer  of  the  germinal  membrane,  and  while  the  intestinal  canal,  etc., 
are  forming  on  the  anterior  surface  of  the  embryo,  which  is  turned  to- 
ward the  ovum,  by  means  of  the  inner  or  mucous  layer,  equally  im- 
portant changes  are*  now  observed  in  the  middle  or  vascular  layer. 
1  In  forming  this  fold,'  says  Dr.  A.  Thompson,  ( the  mucous  layer  is 
reflected  farthest  inward ;  the  serous  layer  advances  least,  and  the  space 
between  them,  occupied  by  the  vascular  layer,  is  filled  up  by  a  dilated 
part  of  this  layer,  the  rudiment  of  the  heart.'  (Op.  Git.,  p.  301.) 

"  While  this  rudimentary  trace  of  the  vascular  system  is  making  its 
appearance,  minute  vessels  are  seen  ramifying  over  the  vesicula  um- 
bilicalis,  forming,  according  to  Bae'r's  observations,  a  reticular  anasto,- 
mosis,  which  unites  into  two  vessels,  the  vasa  omphalo-meseraica. 
(British  and  Foreign  Med.  Rev.  No.  1.)  These  may  be  demonstrated 
with  great  ease  in  the  chick ;  the  cicatricula  increases  in  extent ;  it 
becomes  vascular,  and  at  length  forms  a  heart-shaped  network  of 
delicate  vessels,  which  unite  into  two  trunks,  terminating  one  on  each 
side  of  the  abdomen.  (Fig.  38.) 

"  The  umbilical  vesicle  now  begins  to  separate 
itself  more  and  more  from  the  abdomen  of  the 
fetus,  merely  a  duct  of  communication  passing  to 
that  portion  of  it  which  forms  the  intestinal  canal. 
The  first  rudiment  of  the  cord  will  be  found  at 
this  separation ;  its  fetal  extremity  remains  for  a 
long  time  funnel-shaped,  containing,  beside  a  por- 
tion of  intestine,  the  duct  of  the  vesicula  umbili- 
calis,  the  vasa  omphalo-meseraica  (the  future  vena  ^^  7£?^L£Z 
portse),  the  umbilical  vein  from  the  collected  ven-  wi'«n  which  at  A,  is  the 

T    i  />   ,1          i  •     •  n    Fundus  of  the  diminutive 

ous  radicles  of  the  chonon,  and  the  early  trace  of    Human  Aiiantois. 

the  umbilical  arteries.     These  last  named  vessels     c; The  Duct  of  the  Vesi- 

.n  IT  i  n  cula  Umbilicalis,  dividing 

ramity  on  a  delicate  membranous  sac  of  an  elon-  into  two  intestinai  Por- 
gated  form,  which  rises  from  the  inferior  or  cau-  tions' and  besldes  this duct 

X    .  _     ,  .  are  two  vessels  which  are 

dal  extremity  of  the  embryo,  viz.:  the  atlantois;  distributed  upon  the  vesi- 
whether  this  is  formed  bv  a  portion  of  the  mucous  cula  Urabilicalis  and  fwiu 

.  a    reticular     AnactouioBM 

layer  of  the  germinal  vesicle,  in  common  with  the  with   each    other.— From 
other  abdominal  viscera,  appears  to  be  still  uncer-  Baer' 
tain ;  in  birds  this   may   be  very  easily  demonstrated  as  a  vascular 
vesicle  arising  from  the   extremity  of  the  intestinal  canal ;    and   in 
mammalia,  connected  with  the  bladder  by  means  of  a  canal  called 


136  KING'S  ECLECTIC  OBSTETRICS. 

urachux;  from  its  sausage-like  shape,  it  has  received  the  name  of 
allantois. 

"  The  existence  of  an  allantois  in  the  human  embryo  has  been  long 
inferred  from  the  presence  of  a  ligamentous  cord,  extending  from  the 
fundus  of  the  bladder  to  the  umbilicus,  like  the  urachus  in  animals. 
But  from  the  extreme  delicacy  of  the  allantois,  and  from  its  functions 
revising  at  a  very  early  period,  it  had  defied  all*research,  until  lately, 
when  it  has  been  satisfactorily  demonstrated  in  the  human  embryo  by 
Baer  and  Rathke.  It  occupies  the  space  between  the  chorion  and  am- 
nion,  and  gives  rise  occasionally  to  a  collection  of  fluid  between  these 
membranes,  familiarly  known  by  the  name  of  the  liquor  amnii  spurius, 
which,  strictly  speaking,  is  the  liquor  allantoidis. 

"  The  function  of  the  allantois  is  still  in  a  great  measure  unknown. 
In  animals  it  evidently  acts  as  a  species  of  receptaculum  urinse  during 
the  latter  periods  of  ge'station;  but  it  is  very  doubtful  if  this  be  its 
use  during  the  earlier  periods.  It  does  not  seem  directly  connected 
with  the  process  of  nutrition,  which  at  this  time  is  proceeding  so 
rapidly,  first  by  means  of  the  albuminous  contents  of  the  vitellus,  or 
vesicula  umbilicalis,  and  afterward,  by  the  absorbing  radicles  of  the 
chorion;  but,  from  analogy  with  the  structure  of  the  lower  classes  of 
animals,  it  would  appear  that  it  is  intended  to  produce  certain  changes 
in  the  rudimentary  circulation  of  the  embryo,  similar  to  those  which, 
at  a  later  period  of  pregnancy,  are  effected  by  means  of  the  placenta, 
and  after  birth,  by  the  lungs,  constituting  the  great  functions  of  res- 
piration. 

"  In  many  of  the  lower  classes  of  animals  respiration  (or  at  least 
the  functions  analogous  to  it)  is  performed  by  organs  situated  at  the 
inferior  or  caudal  extremity  of  the  animal;  thus,  for  instance,  certain 
insect  tribes,  as  in  hymenoptera,  or  insects  with  a  sting,  as  wasps, 
bees,  etc.;  in  diptera,  or  insects  with  two  wings,  as  the  common  fly; 
and  also  the  spider  tribe,  have  their  respiratory  organs  situated  in  the 
lower  part  of  the  abdomen.  In  some  of  the  Crustacea,  as,  for  instance, 
the  shrimp,  the  organs  of  respiration  lie  under  the  tail,  between  the 
fins,  and  floating  loosely  in  the  water.  Again,  some  of  the  mollusca, 
viz.:  the  cuttlefish,  have  the  respiratory  organs  in  the  abdomen.  We 
also  know  that  many  animals,  during  the  first  periods  of  their  lives, 
respire  by  a  different  set  of  organs  to  what  they  do  in  the  adult  state ; 
the  most  familiar  illustration  of  this  is  the  frog,  which,  during  its  tad- 
pole state,  lives  entirely  in  the  water. 

"  As  the  growth  of  the  embryo  advances,  other  organs,  whose  func- 
tion is  as  temporary  as  that  of  the  allantois,  make  their  appearance : 


THE    FETUS    AND    ITS    DEVELOPMENT. 


137 


these  also  correspond  to  the  respiratory  organs  of  a  lower  class  of  an- 
imals, although  higher  -than  those  to  which  we  have  just  alluded — we 
mean  branchial  processes,  or  gills.  (Fig.  39.)  It  is  to  Professor 
Eathke  (Acta  Naturce  Curios.,  vol.  xiv),  that  we  are  indebted  for 
pointing  out  the  interesting  fact,  that  several  transverse,  slit-like  aper- 
tures may  be  detected  on  each  side  of  the  neck  of  the  embryo,  at  a 
very  early  stage  of  development.  In  the  chick,  in  which  he  first  ob- 
served it,  it  takes  place  about  the  fourth  day  of  incubation :  at  this 
period  the  neck  is  remarkably  thick,  and  contains  a  cavity  which  com- 
municates inferiorly  with  the  esophagus  and  stomach,  and  opens  ex- 
ternally on  each  side  by  means  of  the  above-mentioned  apertures, 
precisely  as  is  observed  in  fishes,  more  especially  the  shark  tribe; 
these  apertures  are  separated  from  each  other  by  lobular  septa,  of 
exceedingly  soft  and  delicate  structure.  Rathke  observed  the  same 
structure  in  the  embryo  of  the  pig,  and  other  mammalia :  and  Baer 
has  since  shown  it  distinctly  in  the  human  embryo.  It  is  curious  to 
see  how  the  vascular  system  corresponds  to  the  grade  of  development 
then  present:  the  heart  is  single,  consisting  of  one  auricle  and  one 
ventricle;  the  aorta  gives  off  four  delicate,  but  perfectly  simple 
branches,  two  of  which  go  to  the  right,  and  two  to  the  left  side :  each 
of  these  little  arteries  passes  to  FlG  39 

one  of  the  lobules,  or  septa,  at 
the  side  of  the  neck,  which  cor- 
respond to  gills,  and  having  again 
united  with  three  others,  close  to 
what  is  the  first  rudiment  of  the 
vertebral  column,  they  form  a 
single  trunk,  which  afterward  be- 
comes the  abdominal  aorta.  In 
a  short  time  these  slit-like  open- 
ings begin  to  close ;  the  branchial 
processes  or  septa  become  ob- 
literated, and  indistinguishable 
from  the  adjacent  parts;  the  heart 
looses  the  form  of  a  single  heart ;  a  crescentic  fold  begins  to  mark  the 
future  division  into  two  ventricles,  and  gradually  extends  until  the 
septum  between  them  is  completed.  It  is  also  continued  along  the 
bulb  of  the  aorta,  dividing  it  into  two  trunks,  the  aorta  proper,  and 
pulmonary  artery :  at  the  upper  part  the  division  is  left  incomplete,  so 
that  there  is  an  opening  from  one  vessel  to  the  other,  which  forms  the 


A.  Branchial  Processes.      D.  Allantois. 

U.  Vesicula  Umbilicalis.    E.  Amnion. 

C.  Vitellus.  From  Baer. 


138  KING'S  ECLECTIC  OBSTETRICS. 

duct  us  arteriosus.*  A  similar  process  takes  place  iu  the  auricles,  the 
foramen  ovalc  being  apparently  formed  in  the  same  manner  as  the 
ductus  arteriosus;  these  changes  commence  in  the  human  embryo 
about  the  fourth  week,  and  are  completed  about  the  seventh. 

"At  first  the  body  of  the  embryo  has  a  more  elongated  form  than 
afterward,  and  the  part  which  is  first  developed  is  the  trunk,  at  the 
upper  extremity  of  which  a  small  prominence,  less  thick  than  the 
middle  part,  and  separated  from  the  rest  of  the  body  by  an  indenta- 
tion, distinguishes  the  head.  There  are  as  yet  no  traces  whatever 
of  extremities,  or  of  any  other  prominent, parts;  it  is  straight,  or 
nearly  so,  the  posterior  surface  slightly  convex,  the  anterior  slightly 
concave,  and  rests  with  its  inferior  extremity  directly  upon  the  mem- 
branes, or  by  means  of  an  extremely  short  umbilical  cord. 

"  The  head  now  increases  considerably  in  proportion  to  the  rest 
of  the  body ;  so  much  so,  that  at  the  beginning  of  the  second  month, 
p  G  40  it  equals  nearly  half  the  size  of  the  whole  body : 

previous  to,  and  after  this   period,  it   is   usually 
smaller.     The  body  of  the  embryo  becomes  con- 
siderably curved,  both  at  its  upper  as  well  as  its 
lower   extremity,   although   the    trunk    itself   still 
continues  straight.     The  head  joins  the  body  at  a 
right  angle,  so  that  the  part  of  it  which  corres- 
ponds to  the  chin  is  fixed  directly  upon  the  upper 
DIAGRAM  OF  THE  FE-   Par^   °^  ^ne   breast;    nor  can  any  traces  of  neck 
TUS     AND     MEM-  be  discerned,  until  nearly  the  end  of  the  second 
BRANES,  ABOUT  THE  month.     (Fig.  40.) 

"The  inferior  extremity  of  the  vertebral  column, 

A.  Vesicula     Umbilicalis,        i_  •    i_        L    .c  11          ^i  T  /»  j-i 

already  passing  into  wnicn  at  nrst  resembles  the  rudiment  of   a   tail, 
the  ventricular  ami   becomes  shorter  toward  the  middle  of  the  third 

rectum  intestine  at  G.  ,1  j     ,    i  />  i 

B.  Vena  and  arteria  Om-  montn,  and  takes  a  curvature  forward  under  the 

phaio-meseraica.         rectum.     In  the  fifth  week  the  extremities  become 

C.Allantois  springing  from        -Mil 

the  pelvis  with  the  visible,  the  upper  usually  somewhat  sooner  than 

D.  Embryo*8' Ane™S'      the  lower> in  the  form  of  sma11  blunt  prominences— 

E,  Amnion.  the  upper  close  under  the  head,  the  lower  near  the 

-From  ca™.  caudal  extremity  of  the  vertebral  column.  Both 
are  turned  somewhat  outward,  on  account  of  the  size  of  the  abdomen; 
the  upper  are  usually  directed  somewhat  downward,  the  lower  ones 
somewhat  upward. 

•In  making  these  observations  upon  the  formation  of  the  ductus  arteriosus,  we  must 
request  our  readers  to  consider  this  as  still  an  unsettled  question. 


THE    FETUS    AND    ITS    DEVELOPMENT.  139 

"  The  vesicula  umbilicalis  may  still  be  distinguished  in  the  second 
month  as  a  small  vesicle,  not  larger  than  a  pea,  near  the  insertion 
of  the  cord,  at  the  navel,  and  external  to  the  amnion.  From  the 
trunk,  which  is  almost  entirely  occupied  by  the  abdominal  cavity, 
arises  a  short,  thick  umbilical  cord,  in  which  some  of  the -convolutions 
of  the  intestines  may  still  be  traced.  Beside  these,  it  usually  contains, 
as  already  observed,  the  two  umbilical  arteries  and  the  umbilical  vein, 
the  urachus,  the  vasa  omphalo-meseraica,  or  vein  and  artery  of  the 
vesicula  umbilicalis,  and  perhaps,  even  at  this  period,  the  duct  of 
communication  between  the  intestinal  canal  and  vesicula  umbilicalis, 
the  fetal  extremity  of  which,  according  to  Professor  Oken's  views, 
forms  the  processus  vermiformis. 

"  The  hands  seem  to  be  fixed  to  the  shoulders  without  arms,  and  thb 

FIG,  41. 


DIAGRAM  OF  THE  FETUS  AND  MEMBRANES,  ABOUT  THE  SIXTH  WEEK. 

A.  Chorion.  G.  Communicating   Canal   between  the  Vesicula 

B.  The  larger  Absorbent  Extremities,  the  Site  of  Umbilicalis  and  Intestine. 

the  Placenta.  H.  Vena  Umbilicalis. 

C   Allantois.  II.  Arterise  Umbilicalis. 

D  Amnion.  K.  Arteries  Omphalo-meseraica. 

E.  Urachus.  L.  Ven»  Omphalo-meseraica. 

E.  Bladder.  N.  Heart. 

F.  Vesicula  Umbilicalis.  O.  Rudiment  of  Superior  Extremity. 

P.  Rudiment  of  Lower  Extremity.— From  Cants. 

feet  to  adhere  to  the  ossa  ilii;  the  liver  seems  to  fill  the  whole  abdo- 
men ;  the  ossa  innominata,  the  ribs,  and  scapulae,  are  cartilaginous. 

"  In  a  short  time,  the    little   stump-like  prominences  of  the   ex- 
tremities become  longer,  and  are  now  divided  into  two   parts,  the 


140  KI.Mi's    KCLKCTIC    OBSTETRICS. 

superior  into  the  hand  and  the  fore-arm,  the  inferior  into  the  foot 
and  leg;  in  one  or  two  \\vrks  later,  the  arms  and  thighs  are  visible. 
(/•'///.  11.)  These  parts  of  the  extremities,  which  are  formed  later 
than  the  others,  are  at  first  smaller,  but  as  they  are  gradually  developed 
they  become-  larger.  When  the  limbs  begin  to  separate  into  an  upper 
and  lower  part,  their  extremities  become  rounder  and  broader,  and 
divided  into  the  fingers  and  toes,  which  at  first  are  disproportionately 
thick,  and  until  the  end  of  the  third  month  are  connected  by  a  mem- 
1  >  numus  substance  analogous  to  the  webbed  feet  of  water-birds;  this 
membrane  gradually  disappears,  beginning  at  the  extremities  of  the 
fingers  and  toes,  and  continuing  the  division  up  to  their  insertion. 
The  external  parts  of  generation,  the  nose,  ears,  and  mouth,  appear 
after  the  development  of  the  extremities.  The  insertion  of  the  umbili- 
cal cord  changes  its  situation  to  a  certain  degree;  instead  of  being 
nearly  at  the  inferior  extremity  of  the  fetus, 'as  at  first,  it  is  now 
situated  higher  up,  on  the  anterior  surface  of  the  abdomen.  The 
comparative  distance  between  the  umbilicus  and  pubis  continues  to 
increase,  not  only  to  the  full  period  of  gestation,  when  it  occupies  the 
middle  point  of  the  length  of  the  child's  body,  as  pointed  out  by 
Chaussier,  but  even  to  the  age  of  puberty,  from  the  relative  size 
of  the  liver  becoming  smaller. 

"  Though  the  head  appears  large  at  first,  and  for  a  long  time  con- 
tinues so,  yet  its  contents  are  tardy  in  their  development,  and  until 
the  sixth  month  the  parietes  of  the  skull  are  in  a  great  measure  mem- 
branous or  cartilaginous.  Ossification  commences  in  the  base  of  the 
cranium,  and  the  bones  under  the  scalp  are  those  in  which  this  process 
is  last  completed. 

"  The  contents  of  the  skull  are  at  first  gelatinous,  and  no  distinct 
traces  of  the  natural  structure  of  the  brain  can  be  identified  until  the 
close  of  the  second  month ;  even  then  it  requires  to  -have  been  some 
time  previously  immersed  in  alcohol  to  harden  its  texture.  There  are 
many  parts  of  it  not  properly  developed  until  the  seventh  month.  In 
the  medulla  spinalis  no  fibers  can  be  distinguished  until  the  fourth 
month.  The  thalami  nervorum  opticorum,  the  corpora  striata,  and 
tubercula  quadrigemina,  are  seen  in  the  second  month ;  in  the  third, 
the  lateral  and  longitudinal  sinuses  can  be  traced,  and  contain  blood. 
In  the  fifth  we  can  distinguish  the  corpus  callosum  ;  but  the  cerebral 
mass  has  yet  acquired  very  little  solidity,  for  until  the  sixth  month  it 
is  almost  serai-fluid.  (Campbell's  System  of  Midwifery.) 

"  About  the  end  of  the  third,  during  the  fourth,  and  the  beginning 
of  the  fifth  months,  the  mother  begins  to  be  sensible  of  the  move- 


THE    FETUS    AM)    ITS'   DEVELOPMENT.  141 

Dients  of  the  fetus.  These  motions  are  felt  sooner  or  later,  according 
to  the  bulk  of  the  child,  the  size  and  shape  of  the  pelvis,  and  the 
quantity  of  fluid  contained  in  the  amnion ;  the  waters  being  in  larger 
proportionate  quantity  the  younger  the  fetus. 

"  The  secretion  of  bile,  like  that  of  the  fat,  seems  to  begin  toward 
the  middle  of  pregnancy,  and  tinges  the  meconium,  a  mucous  secretion 
of  the  intestinal  tube,  which  had  hitherto  been  colorless,  of  a  yellow 
color.  Shortly  after  this  the  hair  begins  to  grow,  and  the  nails  are 
formed  about  the  sixth  or  seventh  month.  A  very  delicate  membrane 
(membrana  pupillaris),  by  which  the  pupil  has  been  hitherto  closed, 
now  ruptures,  and  the  pupil  becomes  visible.  The  kidneys,  which  at 
first  were  composed  of  numerous  glandular  lobules  (seventeen  or 
eighteen  in  number),  now  unite,  and  form  a  separate  viscus  on  each 
side  of  the  spine ;  sometimes  they  unite  into  one  large  mass,  an  inter- 
mediate portion  extending  across  the  spine,  forming  the  horseshoe 
kidney. 

"  Lastly,  the  testes,  which  at  the  first  were  placed  on  each  side  of 
the  lumbar  vertebrae,  near  the  origin  of  the  spermatic  vessels,  now  de- 
scend along  the  iliac  vessels  toward  the  inguinal  rings,  directed  by  a 
cellular  cord,  which  Hunter  has  called  Gubernaculum  testis :  they  then 
pass  through  the  openings,  carrying  before  them  that  portion  of  the 
peritoneum  which  is  to  form  their  tunica  vaginalis. 

"  The  length  of  a  full-grown  fetus  is  generally  about  eighteen  or 
nineteen  inches ;  its  weight  between  six  and  seven  pounds.  The  dif- 
ferent parts  are  well  developed  and  rounded ;  the  body  is  generally 
covered  with  the  vernix  caseosa  ;*  the  nails  are  horny,  and  project  be- 
yond the  tips  of  the  fingers,  which  is  not  the  case  with  the  toes ;  the 
head  has  attained  its  proper  size  and  hardness ;  the  ears  have  the  firm- 
ness of  cartilage ;  the  scrotum  is  rugous,  not  peculiarly  red,  and 
usually  containing  the  testes.  In  female  children,  the  nymphse  are 
generally  covered  entirely  by  the  labia,  the  breasts  project,  and  in  both 
sexes  frequently  contain  a  milky  fluid.  As  soon  as  a  child  is  born, 
which  has  been  carried  the  full  time,  it  usually  cries  loudly,  opens  its 


*The  vernix  caseosa  is  a  viscid,  fatty  matter,  of  a  yellowish-white  color,  adhering 
to  different  parts  of  the  child's  body,  and  in  some  cases  in  such  quantity  as  to  cover 
the  whole  surface ;  it  seems  to  be  a  substance  intermediate  between  fibrine  and  fat, 
having  a  considerable  resemblance  to  spermaceti.  From  the  known  activity  of  the 
sebaceous  glands  in  the  fetal  state,  and  from  the  smegma  being  found  in  the  greatest 
quantity  about  the  head,  armpits,  and  groins,  where  these  glands  are  most  abundant, 
there  is  every  reason  to  consider  it  as  the  secretion  of  the  sebaceous  glands  of  the  ffkin 
during  the  latter  months  of  pregnancy. 


14:2  KING'S   KCLFCTIC  OI-.STKTRICS. 

eyes,  and  moves  its  arms  and  legs  briskly;  it  soon  passes  urine  and 
fteoes,  and  greedily  takes  the  nipple.     (Xsegel&'s  Hebammenbuch.') 

"Tlm<  then,  in  the  space  of  forty  weeks,  or  ten  lunar  months,  from 
an  inappreciable  point,  the  fetus  attains  a  medium  length  of  about 
eighteen  or  nineteen  inches,  and  a  medium  weight  of  between  six  and 

.-rvril   pounds." 


CHAPTER    XVI. 

POSITION,      NUTRITION,     RESPIRATION,     CIRCULATION,     DIMENSIONS, 
AND    DEATH    OF    THE    FETUS SUPERFETATION. 

IT  was  formerly  believed  that  the  fetus  in  utero  maintained  a  sitting- 
position  during  the  early  months  of  pregnancy,  and  that  as  it  pro- 
gressed in  its  development,  the  superior  weight  of  the  head,  effected  a 
revolution,  so  that  at  the  latter  period  of  pregnancy  its  position  was 
reversed,  the  head  being  downward ;  but  this  is  incorrect,  the  position 
of  the  intra-uterine  fetus  remains  unaltered  from  the  commencement 
to  the  termination  of  gestation,  no  matter  what  may  have  been  its 
primary  or  original  position.  Its  usual  position  is  with  the  head 
downward,  the  most  dependent  part  being  the  vertex;  the  head  is 
flexed  forward  so  that  the  chin  rests  on  the  anterior  superior  portion 
of  the  breast;  the  thighs  are  drawn  up  toward  the  abdomen,  with  the 
knees  apart  from  each  other,  and  thrown  upward  so  as  to  strongly  flex 
the  legs  on  the  posterior  surface  of  the  thighs;  the  heels  approximate 
at  the  posterior  part  of  the  thighs,  the  feet  being  usually  crossed ;  the 
arms  rest  upon  the  sides  of  the  thorax,  Avhile  the  fore-arms  are  flexed 
and  crossed  in  front  of  the  sternum ;  the  neck  and  back  are  bent  for- 
ward into  a  curve.  In  this  position  it  constitutes  an  oval  figure,  whose 
long  diameter  is  about  eleven  inches,  and  forms  a  line  nearly  parallel 
with  the  long  diameter  of  the  uterus;  and  we  can  not  conceive  of  a 
more  easy  and  compact  position  for  such  an  irregular  and  bulky  body. 

The  cause  of  the  dependent  position  of  the  head,  which  is  by  far 
more  common  than  any  other,  has  given  rise  to  much  speculation;  it 
has  been  supposed  to  be  the  result  of  gravitation — that  the  fetus  being 
suspended  by  the  umbilical  cord,  its  heaviest  extremity,  the  cephalic, 
would  naturally  fall  downward.  Again,  it  has  been  stated  to  depend 
upon  the  instinctive  will  of  the  fetus  itself,  which  assumes  the  position 
as  the  most  convenient  for  its  intra-uterine  existence,  and  as  the  most 
advantageous  for  an  easy  expulsion.  Various  other  reasons  have  been 


POSITION,  NUTRITION,  RESPIRATION,  ETC.,  OF  THE  FETUS.         143 

given,  but  none  of  them  are  satisfactory,  and  the  subject  remains  in  as 
much  obscurity  as  ever. 

The  principal  functions  of  the  fetus  while  in  its  intra-uterine  con- 
dition, are  nutrition,  respiration,  and  circulation,  upon  each  of  which 
a  brief  notice  will  be  bestowed.  In  relation  to  the  first,  nutrition, 
many  hypotheses  have  been  advanced;  it  is  at  present  supposed  that 
during  the  early  embryonic  life,  nourishment  is  accomplished  by  super- 
ficial imbibition,  or  probably  by  absorption  through  the  villi  of  the 
chorion,  and  that  its  sources  are,  at  first,  the  vitellus,  or  the  liquid  in 
the  umbilical  vesicle,  and  perhaps  the  albuminous  matter  existing  be- 
tween the  amnion  and  chorion;  the  amniotic  liquid,  after  its  formation, 
is  also  considered  to  contribute  much  toward  this  end,  as  it  contains 
several  nutrient  principles.  It  is  probably  absorbed  by  the  cutaneous 
surface,  for  acephalous  fetuses,  and  those  with  the  natural  mucous 
orifices  closed,  as  well  as  those  which  have  been  born  without  a  pla- 
centa or  umbilical  cord,  have  been,  with  these  exceptions,  as  well  de- 
veloped as  the  perfectly-formed  fetus.  It  has  also  been  stated  that 
this  fluid  is  probably  swallowed,  or  conveyed  into  the  digestive  tube, 
from  the  fact  that  hair  and  portions  of  epithelium  have  been  found 
mixed  with  it  in 'the  stomach;  and  the  meconium  is  supposed  to  be 
the  result  of  digestion.  It  has  also  been  suggested  by  Dr.  Montgom- 
ery, that  the  milky  liquid  in  the  decidual  cotyledons,  may  assist  in  the 
nourishment  of  the  fetus.  The  placenta  has  likewise  been  thought  to 
assist  during  the  latter  months  of  pregnancy,  but  this  is  rather  de- 
signed for  hematosis  than  nutrition,  and  acts  as  a  substitute  for  the 
undeveloped  lungs  of  the  fetus,  somewhat  in  the  manner  of  the  gills 
of  fishes,  whose  blood  is  aerated  by  the  water  passing  through  them. 
It  must  be  remembered  that  fetal  nutrition  has  continued  in  instances 
where  the  liquor  amnii  had  been  evacuated  for  weeks,  which  would 
seem  to  indicate  some  other  source  of  nutrition;  beside,  although 
meconium,  hair,  etc.,  have  been  found  in  the  digestive  tube,  still  it 
appears  to  me  that  the  function  of  deglutition  must  be  very  difficult 
to  perform  in  cases  where  inspiration  and  expiration  are  absent,  as 
with  the  fetus.  It  will  thus  be  seen  that  the  subject  of  fetal  nutrition 
is  involved  in  great  obscurity. 

By  FETAL  KESPIKATION,  is  meant,  not  the  inhalation  and 
exhalation  of  atmospheric  air,  such  as  takes  place  after  birth,  but  the 
phenomenon  by  which  the  blood  in  the  placenta  is  modified  to  suit  it 
for  the  purposes  of  fetal  life.  As  with  the  function  of  nutrition,  this 


141  KING'S  ECLECTIC  OBSTETRICS. 

is  also  ;ui  unsettled  and  incomprehensible  subject.  It  is  supposed,  that 
although  the  placenta  may  be  the  medium  by  which  a  vivifying  prin- 
ciple is  taken  from  the  maternal  blood  and  conveyed  to  the  fetal,  yet 
the  materials  which  form  in  the  latter  and  become  unsuited  to  nutri- 
tion, are  not  removed  by  the  placenta  alone,  but  principally  by  the 
liver,  which  employs  the  superabundance  of  carbon  and  hydrogen  to 
fu nn  bile,  as  well  as  to  aid  in  perfecting  its  own  development.  Respi- 
ration and  nutrition  appear  to  exist  together,  acting  in  harmony,  with- 
out disturbing  each  other,  and  both  being  probably  performed  through 
a  similar  means,  that  of  absorption. 

In  the  FETAL  CIRCULATION,  there  are  several  anatomical 
peculiarities,  not  existing  in  the  adult,  which  it  may  be  proper  to 
notice:  1.  There  is  a  vein  termed  the  ductus  venosus,  which  is  situated 
at  the  thick  edge  of  the  liver,  and  communicates  between  the  umbil- 
ical vein  and  the  vena  cava  ascendens  or  inferior  vena  cava;  after 
birth  this  vein  contracts,  closes  on  the  seventh  day,  and  becomes  oblit- 
erated. 2.  In  the  center  of  the  septum,  between  the  auricles,  is  an 
oval  aperture,  called  the  foramen  ovule  or  foramen  of  Botal ;  this  is 
furnished  with  a  valve,  which  it  is  stated  allows  the  blood  from  the 
vena  cava  ascendeus  to  pass  into  the  left  auricle,  without  mingling 
with  the  blood  of  the,  vena  cava  descendens  ;•  after  birth,  this  closes, 
rarely  persisting  beyond  seven  or  eight  days — occasionally  it  remains 
unclosed  during  life,  giving  rise  to  a  morbid  condition  known  as 
morbus  caruleus.  3.  Soon  after  the  origin  of  the  pulmonary  artery,  a 
branch  is  given  off,  which  communicates  between  this  artery  and  the 
aorta,  entering  this  latter  just  below  its  transverse  arch ;  it  is  called 
the  ductus  arteriosus,  and  after  birth  gradually  closes  and  becomes 
obliterated.  4.  The  umbilical  arteries  and  umbilical  vein  have  been 
already  referred  to. 

The  fetal  circulation  is  entirely  independent  of  that  of  the  mother, 
its  blood  resembles  venous  blood,  being  of  a  uniform  dark  color,  and 
becoming  of  a  bright  florid  tint  as  soon  as  exposed  to  the  atmosphere ; 
it  contains  less  fibrin  than  adult  blood,  but  coagulates  on  standing ;  no 
difference  can  be  perceived  between  the  color  of  the  fluid  passing  in 
the  umbilical  arteries  and  that  in  the  umbilical  vein.  Under  the 
microscope  it  presents  corpuscles,  resembling  those  seen  in  the  blood  of 
an  adult. 

The  course  of  the  circulation  is  as  follows :  The  blood  is  conveyed 
from  the  ramifications  of  the  umbilical  vein  in  the  placenta  to  this 
vein;  through  which  it  passes,  traversing  its  whole  length,  to  the 


POSITION,    NUTRITION,   RESPIRATION,   ETC.,  OF    THE    FETUS.      145 

umbilicus;  as  soon  as  it  has  entered  into  the  abdomen  through  the 
umbilical  ring,  it  proceeds  to  the  longitudinal  sinus,  or  fissure  of  the 
liver,  where  a  portion  of  it  flows  into  the  ductus  venosus  which  con- 
veys it  immediately  to  the  vena  cava  ascendens ;  while  the  remainder 
passes  through  the  vena  portse  into  the  liver,  circulates  through  it,  and 
flows  into  the  hepatic  veins  where  it  is  collected  and  also  emptied  into 
the  vena  cava  ascendens  just  as  it  is  traversing  the  diaphragm.  It  is 
from  thence  conducted,  together  with  the  blood  conveyed  through  the 
ductus  venosus,  to  the  right  auricle  of  the  fetal  heart,  where  it  is  pre- 
vented from  mixing  with  the  venous  blood  from  the  vena  cava 
descendens  by  the  curtain-like  eustachian  valve,  which  conducts  it 
through  the  foramen  ovale  into  the  left  auricle,  and  then  into  the  left 
ventricle,  which  throws  it  into  the  ascending  aorta,  through  which  it  is 
distributed  to  all  parts  of  the  body,  but  especially  to  the  head  and 
superior  extremities.  The  venous  blood  carried  by  the  vena  cava 
descendens  into  the  right  auricle  is  at  the  same  time  directed  by  the 
eustachian  valve  into  the  right  ventricle. 

The  arterial  blood  having  supplied  the  superior  parts  of  the  fetus, 
it  returns  from  these  parts  through  the  jugular  and  axillary  veins, 
passes  into  the  subclavians,  and  then  into  the  vena  cava  descendens, 
through  which  it  flows  into  the  right  auricle,  then  into  the  right  ven- 
tricle, and,  together  with  that  portion  which  passed  into  the  right 
ventricle  without  having  entered  into  the  foramen  ovale,  is  thrown 
into  the  pulmonary  artery,  from  which  a  portion  is  conveyed  to  the 
lungs,  while  the  major  part  passes  through  the  ductus  arteriosus  into 
the  descending  aorta,  where  it  mixes  with  the  blood  from  the  left 
ventricle,  not  required  for  the  head  and  superior  extremities,  and 
flows  along  with  it  to  the  descending  aorta.  That  portion  which 
entered  the  lung  through  the  pulmonary  artery  returns  by  the  pul- 
monary veins  to  the  left  auricle,  and  thence  to  the  left  ventricle,  and 
into  the  descending  aorta,  where  it  mixes  as  just  stated  above.  A 
part  of  the  blood  in  the  descending  aorta  is  distributed  to  the  viscera 
and  inferior  extremities,  while  the  larger  portion  returns  to  the 
placenta,  through  the  umbilical  arteries,  there  to  be  revivified,  and  be 
again  taken  up  by  the  umbilical  vein  to  traverse  the  same  route  as 
before.  (Fig.  42.) 

From  this  arrangement  of  the  circulation  it  will  be  seen  that  the 
blood  with  which  the  head  and  superior  extremities  are  furnished,  is 
nearly  fresh  and  pure  from  the  placenta,  while  that  flowing  through 
the  inferior  parts  of  the  fetus,  having  previously  circulated  through 
the  system,  must  be  less  pure ;  and  this  may,  probably,  be  a  reason  why 
10 


146 


!•:<  I.KCTIC    OBSTETRICS. 


FIG.  42. 


DAIQKAM  OP  THE  FETAL  CIRCULATION. 


1.  Umbilical  Cord,  consisting  of  the  Umbili- 

cal Vein,  and  two  Umbilical  Arteries. 

2.  Placenta. 

3.  Umbilical    Vein     dividing    into     three 

branches. 
4  4.  Two  branches  of  the  vein  to  be  distributed 

to  the  Liver. 

6.  Ductus  Venosus,  or  third  branch  of  the 
Umbilical  Vein. 

6.  Inferior  Vena  Oava  into  which  the  Ductus 

Venosus  enters. 

7.  Portal  Vein,  which  returns  the  blood  from 

thb  Intestines,  and  unites  with  the 
right  Hepatic  branch. 

8.  Right  Auricle,  through  which  the  blood 

passes  to  the  left  Auricle. 

9.  Left  Auricle. 

10  Left  Ventricle,  through  which  the  blood 

pastes  to  the  arch  of  the  Aorta. 
11.  Arch  of  the  Aorta,  from  which  the  blood 
is  distributed,  through  its  branches,  to 
the  head  and  upper  extremities. 
13  18.  The  Arrows  represent  the  return  of  the 
blood  from  the  head  and  superior  ex- 
tremities through  the  Jugular  and  Sub- 
clavian  Veins  to 

14.  The  Superior  Veno  Cava,  to  the  right  Au- 

ricle, and  in  the  course  of  the  Arrow, 
through 

15.  The  Eight  Ventricle  to 

16.  The  Pulmonary  Artery. 

17.  The  Ductus  Arteriosus,  a  proper  contin- 

uation of  the  Pulmonary  artery;  the 
commencement  of  the  fight  and  left 
Pulmonary  Artery,  are  seen  on  each 
side. 

18  18.  The  descending  Aorta,  joined  above  by 
the  Ductus  Arteriosus  ;  further  down 
it  divides  into  the  common  Iliacs, 
which  become  the  Umbilical  Arteries. 

19.  The  Umbilical  Arteries  which  return  the  blood  along  the  cord  to  the  Placenta,  while  the  External 

Iliacs  are  continued  to  the  lower  extremities. 

20.  The  External  Iliacs ;  the  Arrows  making  the  return  of  the  venous  blood  by  the  Veins  to  the  In- 

ferior Cava.    (Neitt  and  Smith.) 

the  head  and  superior  extremities  are  more  rapidly  developed  than  the 
inferior  portions  of  the  fetus. 

•Previous  to  birth,  the  proper  functions  of  the  lungs  are  not 
required,  and  they  are  small,  dense,  firm,  and  unaerated,  being 
nourished  by  small  branches  passing  from  the  pulmonary  artery; 
but  after  birth,  considerable  change  ensues,  the  lungs  become  more 
or  less  inflated  with  atmospheric  air,  and  pulmonary  circulation  is 
established.  The  foramen  ovale  is  closed  by  the  valve  perfected  for 
this  purpose,  which  closure  propels  all  the  blood,  entering  the  right 
auricle,  from  the  ascending  and  descending  cava,  immediately  into  the 
right  ventricle ;  from  thence  it  is  propelled  into  the  pulmonary  ar- 


POSITION,  NUTRITION,  RESPIRATION,  ETC.,  OF   THE    FETUS.       147 

teries  (which  increase  in  diameter),  and  passes  into  the  lungs,  where, 
from  the  action  of  the  atmospheric  oxygen,  it  is  converted  into  arterial 
blood.  The  ductus  arteriosus  being  now  useless,  gradually  contracts 
and  disappears.  The  blood  from  the  inferior  extremities,  not  being 
able  to  pass  through  the  umbilical  arteries,  flows  through  the  vena 
cava  ascendens  into  the  right  auricle  and  ventricle  of  the  heart,  thence, 
as  above,  into  the  lungs,  and  the  circulation  becomes  changed  from 
that  of  the  intra-uterine  to  that  of  the  extra-uterine  or  adult.  In  ad- 
dition, other  changes  also  occur,  the  liver  becomes  more  active,  the 
excretory  functions  of  the  kidneys  and  intestinal  canal  become  estab- 
lished, and  proper  digestion  of  the  food  received  into  the  stomach 
takes  place. 

The  dimensions,  appearances,  and  weight  of  the  fetus  at  different  pe- 
riods of  its  mtra-uterine  development,  have  been  somewhat  accurately 
ascertained  by  various  investigators;  and  as  it  is  not  only  a  matter  of 
•mere  curiosity,  but  frequently,  one  of  great  practical  importance,  in  a 
medico-legal  sense,  to  determine  the  age  of  the  expelled  fetus,  it  is 
necessary  that  the  student  should  be  informed  on  these  points.  The 
following  summary  of  statements  of  various  observers  are  therefore 
presented  : 

The  first  distinct  microscopic  view  which  can  be  had  of  the  embryo 
is  about  the  third  or  fourth  week;  it  is  oblong,  swollen  in  the  middle, 
bluntly  pointed  at  one  extremity,  obtuse  at  the  other,  and  is  slightly 
curved  forward ;  it  is  semi-opaque,  of  a  gelatinous  consistence,  grayish- 
white  color,  varying  from  two  to  five  lines  in  length,  and  weighing 
one  or  two  grains.  It  is  surrounded  by  the  amnion,  and  has  a  vermi- 
•form  or  serpent-like  appearance.  Its  head  appears  as  a  small  tubercle, 
separated  from  the  body  by  a  notch ;  its  mouth  is  indicated  by  a  cleft ; 
its  rudimentary  eyes  by  two  black  points ;  its  caudal  extremity  is 
slender,  and  a  white  line  may  be  observed  in  it,  which  indicates  the 
continuation  of  the  medulla  spinalis.  The  members  present  nipple- 
like  protuberances  ;  the  liver  occupies  the  whole  abdomen,  the  cavity 
of  which  is  opened  in  front  to  a  considerable  extent ;  the  umbilical 
vesicle  is  very  large ;  the  chorion  is  villous,  the  villosities  being  dif- 
fused over  its  whole  surface. 

At  the  sixth  week  (Fig.  41),  its  length  is  from  nine  to  twelve  lines ; 
its  weight  from  forty  to  seventy-five  grains;  and  all  its  parts  are 
distinct.  The  head  has  greatly  increased,  and  is  separated  from  the 
thorax  by  the  depression  of  the  neck ;  the  eyes  still  appear  as  two  dark 
epots;  the  mouth  presents  a  small,  triangular  orifice;  the  face  is 


148  KINii's    KOI,ECTIC    OKSTKTRICS. 

distinct  from  the  cranium  ;  the  hands,  fore-arms  and  fingers  can  be 
recognized;  the  chiviclc  and  maxillary  bone  present  a  point  of  ossifi- 
cation; the  legs  and  feet  are  situated  near  the  anus,  which  remains 
closed  ;  the  umbilicus,  for  the  attachment  of  the  cord,  may  be  observed, 
the  cord  consisting  of  the  omphalo-mesenteric  vessels,  a  portion  of 
the  urachus,  a  part  of  the  intestinal  tube,  and  of  filaments,  which 
represent  the  umbilical  vessels;  the  formation  of  the  placenta  com- 
mences ;  the  chorion  and  amnion  are  separated  from  each  other ;  and 
the  umbilical  vesicle  is  very  large.  The  divisions  of  the  vertebra?  can 
be  seen,  also  the  imperfect  interventricular  septum  of  the  heart,  and 
the  lungs,  which  appear  as  five  or  six  lobules,  in  which  the  bronchii 
may  be  distinguished  terminating  in  somewhat  swollen  culs-de-sac. 
Extending  from  the  lung  to  the  bottom  of  the  pelvis,  along  each  side 
of  the  vertebral  column,  may  be  seen  two  glandular  structures ;  these 
are  the  Wolffian  bodies,  or  false  kidneys,  and  are  constituted  of  an 
excretory  canal  running  through  their  whole  length.  Alongside  of 
this  canal  may  be  observed  another,  which  becomes,  according  to  the 
gender  of  the  new  being,  either  the  oviduct  or  the  vas  deferens.  Both 
of  these  canals  empty  below  into  the  transitory  pouch  or  cloaca. 

In  early  embryonic  life  may  be  seen  on  each  side  of  the  neck  four 
transverse  fissures;  these  open  into  the  pharynx,  are  separated  from 
each  other  by  fleshy  bands,  and  are  analogous  to  the  bronchial  arcs 
of  fishes.  The  aorta  sends  three  or  four  branches  to  these  fissures, 
but  which,  together  with  the  fissures  soon  become  obliterated,  but  two 
on  the  left  side  remaining,  one  of  which  becomes  the  arch  of  the 
aorta,  while  the  other  forms  the  common  trunk  of  the  pulmonary 
arteries ;  the  first  branchial  fissure  of  each  side  also  remains,  and  is 
converted  into  the  external  ear.  The  upper  jaw  is  composed  of  a 
pimple  or  piece  on  each  side,  which  gradually  approximate  and  form 
a  single  body;  the  nostrils  are  each  split  down  to  the  mouth,  and  are 
separated  by  the  incisive  pimples,  but  approach  each  other,  and  assume 
their  proper  form,  as  the  pimples  diminish  in  size ;  and  if  the  progress 
of  this  development  is  arrested,  hare-lip  is  the  result. 

At  two  months,  the  embryo  is  from  one  and  a  half  to  two  inches  in 
length,  and  weighs  from  three  drachms  to  nearly  an  ounce ;  the  head 
forms  about  one-third  of  it,  the  eyes  are  prominent  but  not  yet  covered 
by  the  lids,  which  are  still  rudimentary;  the  nose  forms  an  obtuse 
eminence,  with  rounded  and  separated  nostrils;  the  mouth  is  gaping; 
the  elbows  and  fore-arms  are  detached  from  the  trunk,  and  the  fingers 
are  isolated,  or  adhere  by  a  transparent  gelatinous  substance;  the 
rudimentary  shoulder  and  hips  are  just  observable;  the  penis  or 


POSITION,  NUTRITION,  RESPIRATION,  ETC.,  OF    THE    FETUS.      149 

clitoris  is  apparent,  but  can  not  readily  be  distinguished  from  each 
other,  on  account  of  the  length  of  the  latter.  The  anus  forms  a  small 
conical  projection,  but  is  imperforate,  and  its  location  is  marked  by  a 
dark  spot;  the  rudiments  of  the  lungs,  spleen,  and  supra -renal*  cap- 
sules are  observed ;  the  ccecum  is  placed  behind  the  umbilicus ;  the 
digestive  tube  is  withdrawn  into  the  abdomen;  the  urachus  is  visible; 
osseous  points  are  apparent  in  the  frontal  bone  and  in  the  ribs;  the 
ehorion  commences  to  come  in  contact  with  the  amnion  at  the  point 
opposite  the  insertion  of  the  placenta,  which  now  begins  to  assume 
its  regular  form ;  the  cord  is  inserted  low  down  in  the  abdomen,  is 
infundibuliform  in  shape,  and  four  or  five  lines  in  length,  and  the 
umbilical  vessels  commences  their  spiral  twisting;  its  base  contains  a 
portion  of  intestine.  The  umbilical  vesicle  begins  to  disappear.  The 
epidermis  is  distinguishable. 

At  ten  weeks,  the  embryo  is  from  one  and  a  half  to  two  and  a  half 
inches  in  length,  and  weighs  an  ounce,  or  an  ounce  and  a  half;  the 
eye-lids  are  apparent  and  cover  the  eyes,  and  the  lachrymal  puncta 
are  visible ;  the  hips  commence  to  develop  themselves,  and  the  buccal 
fissure  begins  its  obliteration.  The  parietes  of  the  thorax  are  seen, 
and  the  motions  of  the  heart  are  no  longer  visible;  the  fingers  are 
distinct,  and  the  toes  appear  as  tubercles  united  by  some  soft  sub- 
stance; the  cord  assumes  the  spiral  appearance,  is  longer  than  the 
embryo,  is  less  infundibuliform,  is  not  inserted  so  low  down,  and  still 
contains  a  portion  of  intestine. 

At  three  months,  the  embryo  is  from  two  and  a  half  to  five  or  six 
inches  in  length,  and  weighs  from  an  ounce  and  a  half  to  three  or  four 
ounces ;  the  head  is  voluminous,  but  bears  a  better  proportion  to  the 
rest  of  the  body ;  the  eyelids  are  very  distinct,  and  are  in  contact  by 
their  free  margins;  the  pupillary  membrane  is  visible;  the  nose  pro- 
jects ;  the  mouth  is  closed  but  perfectly  delineated ;  the  thorax  is 
well  formed;  the  fingers  are  completely  separated,  and  the  nails  pre- 
sent the  appearance  of  thin  membranous  plates ;  the  inferior  extremi- 
ties are  of  greater  length  than  the  rudimentary  tail ;  the  clitoris  and 
penis  are  very  long,  but  the  sex  •  may  frequently  be  discriminated  by 
a  longitudinal  fissure,  the  edges  of  which  form  the  labia  pudenda; 
the  thymus  gland,  as  well  as  the  supra-renal  capsules  are  present; 
the  ccecum  is  placed  below  the  umbilicus ;  the  cerebrum  is  five  lines 
in  diameter,  the  cerebellum  four,  the  medulla  oblongata  one  and  a 
half,  and  the  medulla  spinalis  three-fourths  of  a  line;  the  two  ven- 
tricles of  the  heart  are  distinct;  the  decidua  reflexa  and  vera  come 
in  contact ;  the  cord  contains  a  little  of  the  gelatin  of  Wharton,  and 


150  KIMi's     K<  LK'TIC    OBSTETRICS. 

umbilical  vessels  which  twist  and  form  long  spiral  turns;  the  placenta 
becomes  completely  isolated,  and  the  allantois,  umbilical  vesicle,  and 
omphalo-mesenteric  vessels  have  disappeared. 

\t  four  montlis,  the  embryo  takes  the  name  of  Fetus.  Its  length  is 
from  five  to  eight  inches,  and  its  weight  from  three  to  seven  or  eight 
ounces.  The  skin  is  rosy,  tolerably  dense,  and  begins  to  be  covered 
with  down ;  and  a  sensible  motion  may  be  perceived  in  the  muscles. 
The  fontanelles  and  sutures  are  very  large,  and  sometimes  whitish 
hairs  may  be  seen  on  the  head;  the  face  is  elongated  but  imperfectly 
developed ;  the  eyes,  nostrils,  and  mouth  are  closed,  and  the  tongue 
and  projection  of  the  chin  are  observable ;  the  membrana  pupillaris  is 
very  evident ;  the  nails  become  more  developed ;  the  sex  may  be  re- 
cognized ;  the  coecum  is  placed  near  the  right  kidney ;  the  gall-bladder 
commences  to  appear ;  meconium  is  found  in  the  duodenum ;  the 
ccecal  valve  is  visible;  the  umbilicus  is  placed  near  the  pubis;  the 
ossicula  auditoria  are  ossified ;  the  superior  part  of  the  sacrum  presents 
points  of  ossification ;  the  decidua  serotina  is  formed ;  and  the  chorion 
and  amnion  are  in  close  contact  with  each  other.  A  fetus  born  at  this 
period  might  live  for  several  hours. 

At  jive  months,  the  length  of  the  fetus  is  from  seven  to  ten  inches, 
and  its  weight  from  seven  to  twelve  ounces.  The  head  is  still  large, 
with  appearances  of  hair ;  white  substance  in  the  cerebellum ;  the 
nails  are  very  distinct ;  the  skin  is  more  consistent,  frequently  pre- 
senting patches  of  sebaceous  matter;  the  heart  and  kidneys  are  very 
voluminous ;  the  ccecum  is  situated  at  the  inferior  part  of  the  right 
kidney;  the  gall-bladder  is  distinct;  points  of  ossification  are  manifest 
in  the  pubis  and  heel ;  germs  of  permanent  teeth  appear ;  the  me- 
coniurn  has  a  yellowish-green  tint,  and  occupies  the  commencement  of 
the  large  intestine ;  the  umbilical  cord  is  longer. 

At  six  months,  the  length  of  the  fetus  is  from  ten  to  twelve  and  a 
half  inches,  and  its  weight  from  twelve  ounces  to  a  pound.  The  liver 
is  large  and  red,  some  fluid  in  gall-bladder.  The  hair  is -longer  and 
thicker,  white  or  silvery;  the  face  of  a  purplish-red;  the  eyelids  some- 
what thicker  but  still  in  contact,  the  pupillary  membrane  also  remains, 
and  the  eyebrows  are  filled  with  delicate  hairs.  The  skin  is  better 
organized,  presenting  some  appearance  of  fibrous  structure,  and 
sebaceous  covering;  the  nails  are  solid;  sacculi  begin  to  appear  in  the 
colon  ;  the  cord  is  inserted  a  little  above  the  pubis;  the  scrotum  is  very 
small,  quite  red,  and  empty,  the  testes  being  near  the  kidneys ;  points 
of  ossification  are  developed  in  the  divisions  of  the  sternum. 

At  seven  months,  the  fetus  is  from  twelve  and  a  half  to  fourteen 


POSITION,  NUTRITION,  RESPIRATION,  ETC.,  OF  THE  FETUS.        151 

inches  in  length,  and  weighs  three  or  four  pounds.  All  its  parts  are 
more  perfectly  developed  and  better  proportioned;  the  brain  possesses 
more  consistency ;  the  skin  is  rosy,  thick  and  fibrous,  with  sebaceous 
covering;  the  eyelids  are  partly  open;  the  pupillary  membrane  disap- 
pears ;  the  iris  commences  as  a  simple  ring,  which  increases  in  a  con- 
centric manner,  ultimately  leaving  an  opening  called  the  pupil;  the 
nails  have  not  yet  reached  the  extremities  of  the  fingers ;  a  point  of 
ossification  is  observed  in  the  astragalus;  the  left  lobe  of  the  liver  is 
nearly  as  large  as  the  right ;  the  gall-bladder  contains  bile ;  nearly  the 
whole  of  the  large  intestine  is  filled  with  meconium ;  valvulse  con- 
niventes  begin  to  appear;  the  coecum  is  placed  in  the  right  iliac  fossa; 
the  testicles  leave  the  kidneys  and  approach  the  inguinal  ring. 

At  eight  months,  the  fetus  is  from  fourteen  to  sixteen  or  eighteen 
inches  in  length,  and  weighs  four  or  five  pounds.  The  skin  is  very 
red,  covered  with  long  down,  and  a  quantity  of  sebaceous  matter, 
called  the  vernix  caseosa,  or  smegma,  which  is  a  secretion  of  the  fetal 
skin,  and  is  found  more  abundantly  on  some  fetuses  than  on  others ;  it 
is  a  fat,  slippery,  viscous  substance,  of  a  yellowish-white  color,  is  in- 
soluble in  water,  alcohol  or  oil,  and  only  partially  soluble  in  potash, 
and  is  apparently  of  service,  during  labor,  by  aiding  to  facilitate  the 
expulsion  of  the  fetus.  The  pupillary  membrane  disappears;  convo- 
lutions appear  in  the  brain;  the  inferior  maxillary  bone,  which  was  at 
first  very  short,  is  now  as  long  as  the  superior ;  the  nails  are  much 
firmer,  and  reach  the  extremities  of  the  fingers ;  a  point  of  ossification 
is  observed  in  the  last  vertebra  of  the  sacrum ;  no  center  of  ossifica- 
tion is  presented  by  the  cartilage  of  the  inferior  extremity  of  the 
femur ;  the  testicles  descend  into  the  internal  ring,  and  one  is  usually 
contained  in  the  scrotum;  generally  that  on  the  left  side;  the  hair  of 
the  head  is  much  darker  and  longer. 

At  full  term,  the  fetus  is  from  sixteen  to  twenty-three  inches  in 
length,  and  weighs  from  five  to  seven,  ten,  and  sometimes  even  twelve 
pounds,  the  average  weight  being  about  six  and  a  half  pounds.  The 
head  is  covered  with  a  greater  or  less  quantity  of  hair,  varying  in 
length  from  six  to  twelve  lines;  the  white  and  gray  substances  of  the 
brain  become  distinct;  convolutions  well  marked;  tlie  pupillary  mem- 
brane no  longer  exists ;  four  portions  of  the  occipital  bone  remain 
distinct;  the  external  meatus  auditorius  still  remains  cartilaginous; 
the  os  hyoides  is  not  yet  ossified ;  the  skin  is  deep  red,  and  covered 
with  sebaceous  matter,  especially  at  the  flexures  of  the  joints ;  the 
liver  descends  to  the  umbilicus ;  the  testes  have  passed  the  inguinal 
ring,  and  are  frequently  found  in  the  scrotum ;  meconium  is  found  at 


152  KING'S  ECLECTIC  OBSTETRICS. 

the  termination  of  the  large  intestine;  the  center  of  the  cartilage  at 
the  lower  extremity  of  the  femur,  exhibits  a  point  of  ossification. 

A  full  developed  fetus  is  characterized  by  a  ready  movement  of  the 
limbs,  an  ability  to  cry,  and  a  capability  of  sucking;  its  mouth,  eye- 
lids, nostrils,  and  ears  are  open ;  the  hair,  eyebrows  and  nails  are  fully 
ilrvrloped;  the  cranial  bones  are  firm,  and  the  edges  of  the  fontanelles 
are  not  far  apart,  the  body  is  of  a  clear  red  color;  and  the  meconium 
is  discharged  within  a  few  hours  after  birth.  The  meconium  is  a  semi- 
fluid, of  a  dark  green  color  at  term,  which  is  found  in  the  fetal  intes- 
tines, and  is  a  mixture  of  bile  with  the  secretions  of  the  mucous 
membrane ;  some  suppose  it  to  be  digested  amniotic  fluid. 

An  immature  fetus  may  be  known  by  its  feeble  motions,  its  small 
size,  and  incapability  of  sucking ;  its  head  is  covered  with  down  or 
sparingly  with  short  hair ;  the  bones  are  soft ;  the  fontanelles  widely 
separated ;  the  skin  is  red  with  blue  streaks ;  the  nails  are  not  per- 
fected; the  eyelids  and  mouth  are  closed;  and  the  urination  and  defe- 
cation are  imperfect. 

As  will  be  stated  under  Abortion,  the  fetus  is  liable  to  numerous 
diseases,  some  of  which  may  be  independent  of  the  condition  of  the 
mother,  while  others  occur  secondarily  through  her.  Cases  of  inter- 
mittent fever  have  occurred  to  the  fetus  where  the  mother  was  laboring 
under  the  disease;  small-pox  has  attacked  the  fetus  both  where  the 
mother  was  suffering  with  it,  and  in  other  instances  where  she  was  en- 
tirely exempt  from  it,  and  the  same  may  be  said  of  measles.  Various 
cutaneous  diseases  have  also  attacked  the  fetus  in  utero,  as  well  as  hy- 
drocephalus,  pleurisy,  abscesses  of  the  lungs,  oedema,  scirrhous  indu- 
ration, tubercles,  lobular  pneumonia,  calcareous  deposition  in  the 
lungs,  peritonitis,  and  enteritis.  It  is  also  especially  liable  to  hyper- 
trophy or  atrophy,  worms,  calculus,  dropsy,  rickets,  caries,  and  necro- 
sis. Various  forms  of  syphilitic  disease  are  very  apt  to  injure  or 
destroy  it,  when  the  system  of  one  or  both  parents  is  contaminated 
with  the  syphilitic  virus.  The  heart,  liver,  kidneys,  stomach,  and 
other  organs  may  become  organically  affected,  and  it  is  by  no  means 
uncommon  to  observe  fractures  and  dislocations  of  various  bones, 
which  took  place  previous  to  birth.  Previous  to  the  expulsion  of  the 
fetus,  it  is  impossible  to  detect  any  of  these  maladies,  and  even  had 
we  the  means  of  doing  so,  it  is  very  doubtful  whether  any  curative  or 
even  palliative  measures  could  be  beneficially  pursued;  the  greater 
part  of  them  may  be  ascertained  after  its  death  and  expulsion,  and  all 
the  advantage  to  be  derived  from  such  information,  at  this  time,  is  to 


POSITION,  NUTRITION,  RESPIRATION,  ETC.,  OF  THE  FETUS.       153 

lead  to  the  adoption  of  such  measures  as  may  prevent  similar  attacks 
in  subsequent  pregnancies. 

The  signs  by  which  we  may  determine  the  death  of  the  fetus,  are  fre- 
quently of  great  importance,  especially  in  reference  to  the  best  time 
for  obstetric  operations,  when  these  have  to  be  performed.  There  are 
no  signs  upon  which,  separately,  the  accoucheur  can  positively  deter- 
mine a  dead  fetus ;  indeed  its  diagnosis  is  extremely  difficult,  and  must 
be  decided  by  the  aggregate  of  symptoms  present.  These  are  named 
by  Dr.  Churchill,  in  his  work  on  Obstetrics,  as  follows : 

1.  The  cessation  of  the  fetal  movements;  but  these  may  be  suspended 
for  several  days,  and  yet  the  fetus  be  alive.  2.  The  subsidence  or 
flaccidity  of  the  abdomen;  this  varies  much  during  pregnancy,  less 
tension  being  present  in  women  who  have  had  several  children.  3. 
The  recession  of  the  umbilicus ;  but  a  dead  fetus  may  remain  in  utero 
for  months  without  this  sign.  4.  The  loose  feel  of  the  uterine  tumor. 
5.  A  rolling  of  the  tumor  in  the  abdomen,  and  a  sensation  of  dead  weight 
and  coldness;  these  may  exist  and  yet  the  fetus  be  alive,  the  rolling 
may  proceed  from  a  loss  of  tone  of  the  abdominal  muscles — women 
who  give  birth  to  a  living  child,  frequently  complain  of  the  uterine 
tumor  feeling  as  a  weight  or  foreign  body  ;  again,  there  is  no  appre- 
ciable difference  between  the  temperature  of  a  living  fetus  and  that  of 
a  dead  one — the  coldness  is  a  mere  sensation  that  may  be  experienced 
independent  of  fetal  death.  6.  The  breasts*  suddenly  become  flaccid, 
and  their  secretions  suppressed ;  this  rarely  occurs  from  any  cause  save 
the  death  of  the  fetus.  7.  The  health  of  the  female  becomes  deteriorated; 
but  a  dead  fetus  has  frequently  been  retained  for  weeks  or  months 
without  any  change. in  the  maternal  health,  beside  the  health  may  be 
impaired  from  other  causes.  8.  Bad  appetite,  sunken  countenance, 
a  dark  areola  around  the  eyes;  feted  breath,  repeated  rigors;  these  are 
all  minor  signs,  and  may  exist  independent  of  pregnancy,  or  when  oc- 
curring during  its  presence  may  be  owing  to  causes  not  connected  with 
the  condition  of  the  fetus ;  yet  taken  in  connection  with  other  signs 
they  may  become  useful  in  aiding  the  diagnosis. 

When  the  motions  of  the  fetus  have  been  very  active  up  to  the 
fifth,  sixth  or  seventh  month,  or  longer,  and  suddenly  subside,  and  at 
the  same  time  the  breasts  which  had  been  firm  and  tense,  become 
flaccid  and  decrease  in  size,  while  the  abdomen  loses  its  previous  tense 
and  rounded  form,  the  uterine  tumor  becoming  weighty  and  rolling 
loosely  in  the  lower  belly,  we  have  almost  a  positive  proof  of  the  death 
of  the  fetus,  which  is  rendered  still  more  certain  by  the  absence  of  the 
beating  of  the  fetal  heart.  But,  although  much  assistance  may  be 


154  KING'S  KCLKCTIC  OBSTETRICS. 

derived  from  the  use  of  the  stethoscope,  yet  it  frequently  proves  un- 
certain, either  from  want  of  tact  and  experience  on  the  part  of  the 
aiiM-ultator,  or  because  the  position  of  the  fetus  may  be  unfavorable  to 
the  transmission  of  sound  to  his  ear,  or  the  pulsations  may  be  tem- 
porarily suspended.  If,  however,  the  pulsations  have  been  distinctly 
heard  on  a  previous  occasion,  and  subsequently  become  suddenly  or 
gradually  inaudible,  the  evidence  in  favor  of  the  death  of  the  fetus,  in 
connection  with  the  other  symptoms,  is  rendered  unequivocal. 

After  the  rupture  of  the  membranes,  there  are  other  diagnostic 
symptoms  of  a  more  determinate  character.  1.  The  liquor  amnii  be- 
comes dark,  thicker  than  usual,  fetid,  and  bloody,  especially  where  the 
fetus  has  been  dead  for  some  time;  but  it  must  be  remembered  that 
these  conditions  have  been  present  with  the  living  fetus.  2.  When 
the  death  is  not  recent,  having  occurred  some  time  previous  to  the 
examination,  the  scalp  will  feel  emphysematous  when  the  finger  is 
pressed  upon  it,  crepitating  under  the  touch,  and  a  portion  of  the 
cuticle  will  peel  off;  where  the  death  is  recent,  the  bones  of  the  skull 
will  overlap  each  other  loosely,  and  the  edges  of  the  bones  will  convey 
a  sensation  of  peculiar  sharpness.  These,  together  with  the  absence 
of  pulsation  at  the  anterior  fontanelle,  and  its  decrease  from  the  col- 
lapse of  the  bones,  are  considered  conclusive  signs. 

In  face  presentations,  the  flabby  lips,  flaccid  and  motionless  tongue, 
and  a  slight  swelling  of  the  presenting  part,  are  evidence  of  the  child's 
death.  In  breech  presentations,  the  finger  can  be  readily  introduced 
within  the  sphincter  ani  in  case  of  death,  which  contracts  and  resists 
the  finger,  if  the  fetus  be  alive ;  the  discharge  of  meconium  is  a  symp- 
tom of  no  value.  In  an  arm  presentation,  the  pulse  at  the  wrist  may 
be  imperceptible,  the  arm  may  become  cold  and  livid,  and  yet  the 
fetus  be  alive;  but  if  the  epidermis  peel  off,  the  child  is  dead.  In 
prolapse  of  the  umbilical  cord,  the  absence  of  pulsation  in  it  is  usually 
regarded  as  conclusive  evidence  of  the  child's  death;  but  this  has 
occurred  and  the  child  been  born  alive. 

Before  closing  this  chapter,  I  will  make  a  few  remarks  on  super- 
fetation,  which  subject  has  not  been  noticed  in  the  preceding  pages. 
By  superfetation  is  meant,  a  second  impregnation  and  conception, 
where  the  female  is  already  pregnant.  The  early  writers  were 
impressed  with  the  belief,  that  such  an  occurrence  was  possible, 
while  among  recent  authors  we  find  a  difference  of  opinion.  The 
reasons  which  have  been  advanced  in  its  favor,  are:  1.  Females,  at 
full  term  of  pregnancy,  sometimes  give  birth  to  a  well-developed 


POSITION,  NUTRITION,  RESPIRATION,  ETC.,  OF  THE  FETUS.         155 

fetus,  and  a  blighted  ovum  at  the  same  time;  or,  where  the  children 
are  living,  one  of  them  will  be  more  matured  than  the  other.  The 
disparity  between  them  has  aiforded  ground  for  belief  that  they  were 
the  products  of  different  impregnations;  but  these  cases  do  not  prove 
superf'etation,  as  it  not  unfrequently  occurs  that  the  development  of 
one  of  the  twins  is  retarded,  or  it  may  die  and  be  expelled  while  the 
other  is  retained;  and  it  is  by  no  means  uncommon  for  one  twin  to  be 
larger  and  more  matured  than  its  fellow. 

2.  Cases  have  been  recorded  where  the  female  has  brought  forth,  at 
one  parturition,  two  children,  one  of  which  was  white,  and  the  other 
black,  or  mulatto.     But  these  cases  have,  so  far  as  I  know,  been  the 
result  of  two  coitions,  shortly  succeeding  each  other,  one  with  a  white 
and  the  other  with  a  black  person.     There  is  abundant  evidence  to 
prove  that  superfetation  of  this  kind  is  possible  at  a  very  early  period 
of  pregnancy;  impregnation  having  taken  place  before  the  canal  of 
the  cervix  became  closed  by  decidual  membrane,  or  by  the  tough, 
gelatinous  secretion  of  the  glandule  Nabothi.     But  after  the  forma- 
tion of  these  substances,  which  effectually  prevents  any  egress  into  the 
uterus,  I  do  not  believe  that  conception  can  occur,  unless,  indeed, 
there  be  some  other  route  through  which  the  semen  can  reach  the  im- 
pregnated ovum,  independent  of  the  uterine  cavity,  and  Fallopian 
tubes. 

3.  Instances  have  been  related  where  from  three  to  four  months 
after  the  delivery  of  a  well-developed  child,  another  child,  fully  ma- 
tured, has  been  born.     In  some  of  these  cases,  the  difficulty  has  been 
removed  by  the  discovery  of  a  double  uterus.     But  where  these  cir- 
cumstances have  happened  with  but  a  single  uterus  present,  if  such  in 
reality  has  ever  occurred,  the  subject  is  involved  in  much  obscurity. 
It  may  be  that  the  development  of  one  fetus  progressed  much  more 
slowly  than  that  of  the  other ;  and  that  when  this  latter  was  born,  the 
uterine  contractions  not  having  destroyed  the  integrity  of  the  mem- 
branes of  the  former,  nor  destroyed  its  utero-placental  attachment,  it 
continued  to  remain  in   utero,  until  its  maturity  again    determined 
uterine  action.     It  has  also  been  supposed  in  cases  of  single  uterus, 
that  this  organ  may  have  been  divided  by  a  longitudinal  septum,  and 
thus  impregnation  could  be  effected  in  each  at  different  periods ;  but 
this  is  as  difficult  to  my  mind  as  in  the  previous  instance,  unless  it  -be 
admitted  in  each,  thai  immaturity  of  the  fetus  favors  protracted  ges- 
tation, and  that  the  contractions  of  the  uterus  to  expel  a  full  grown 
fetus,  do  not,  necessarily,  involve  the  immediate  expulsion  of  another 
in  utero,  but  imperfectly  developed. 


156  KING'S  ECLECTIC  OBSTETRICS. 


CHAPTER    XVII. 

CHANGES  IN  THE  CONDITION  OF  THE   UTERUS   DURING  PREGNANCY. 

FROM  the  moment  of  conception,  the  uterus  gradually  undergoes  a 
series  of  changes,  in  volume,  form,  situation,  and  direction,  a  knowl- 
edge of  all  of  which  is  highly  important  to  the  accoucheur.  These 
changes  occur  both  in  the  neck,  and  in  the  body,  each  of  which  I  will 
review  individually. 

CHANGES  IN  THE  NECK  OF  THE  UTERUS.  As  gestation 
proceeds,  the  congestion  and  ramollissement  of  the  substance  of  the  cer- 
vix gradually  advances,  until  finally  the  whole  neck  becomes  softened. 

Toward  the  end  of  the  first  month,  the  lower  or  inferior  portion  of 
the  cervix  commences  to  undergo  this  change,  which  is  principally  con- 
fined to  the  mucous  covering  of  the  part,  imparting  to  the  finger  a 
fungous  softness,  but  through  which  deeper  pressure  will  detect  the 
firm  consistency  of  the  proper  tissue.  The  softening  always  com- 
mences below  and  advances  upward,  gradually  progressing,  so  that 
at  the  end  of  the  third  month,  or  commencement  of  the  fourth,  this 
modification  extends  into  the  substance  of  the  lips,  softening  them 
through  their  whole  thickness  to  the  extent  of  a  line  and  a  half,  and 
increasing  as  gestation  progresses,  until  at  the  sixth  month  it  embraces 
one-half  of  the  vaginal  projection  of  the  neck.  It  continues  to  ad- 
vance gradually  upward  during  the  last  three  months,  until  finally 
the  whole  cervix,  together  with  the  ring  of  the  internal  orifice  becomes 
so  softened,  that  at  "term"  it  has  occasioned,  in  the  practice  of  the 
inexperienced  physician,  much  difficulty  in  discriminating  it  from  the 
vaginal  walls.  It  may  be  proper  for  me  to  remark  that,  in  five  or  six 
cases,  I  have  encountered  a  cushiony,  spongy  sensation  of  the  inferior 
portion  of  the  uterine  cervix,  the  patients  not  being  pregnant,  but 
laboring  under  abnormal  conditions  of  the  uterus. 

This  ramollissement  of  the  neck  is  an  important  indication  of  preg- 
nancy, being  present  at  an  early  period,  and  is  found  in  all  females 
in  whom  the  neck  is  in  a  normal  condition ;  it  likewise  renders 
material  assistance  in  determining  the  stage  of  pregnancy.  But  in 
the  investigation  of  this  last  point,  it  must  always  be  recollected  that 
in  females  who  have  given  birth  to  a  number  of  children,  the  vaginal 
.projection  of  the  neck  loses  a  considerable  portion  of  its  length,  and 


CHANGES    IN    THE    UTERUS    DURING    PREGNANCY.  157 

consequently,  if  one  half  of  this  projection  has  been  lost,  the  softening 
will  not  commence  in  the  lower  extremity  of  the  remaining  portion, 
until  the  period  at  which  it  would  have  ensued,  were  the  neck  of  its 
original  extent,  or  at  a  period  proportioned  to  the  amount  of  length 
which  has  been  lost.  Thus,  in  a  woman  who  has 'given  birth  to  eight 
or  ten  children,  the  neck  will  vary  very  much  in  the  extent  of  its 
softening  at  the  sixth  month,  when  compared  with  that  of  a  female 
at  the  same  stage  of  gestation,  who  has  borne  only  two  or  three 
children.  In  primiparse,  or  women  with  their  first  child,  this  soft- 
ening progresses  more  slowly  than  in  multiparse,  or  women  who  have 
previously  had  children. 

Beside  the  softening  of  the  neck,  it  undergoes  other  modifications. 
During  the  early  months  of  pregnancy  it  becomes  thicker,  with  an 
increase  of  its  volume,  more  especially  at  its  superior  portion;  it  is 
also  found  at  a  lower  point  within  the  vagina,  inclined  a  little  to  the 
left,  with  the  os  tincse  looking  more  toward  the  pubis,  and,  as  a  larger 
extent  of  it  can  now  be  felt  and  examined  by  the  finger,  it  has  given 
rise  to  an  erroneous  impression  that  its  length  was  likewise  increased. 
At  the  fifth  month  the  cervix  looks  more  toward  the  sacrum,  and  still 
a  little  to  the  left,  becomes  more  elevated  and  is  difficult  to  reach; 
this  elevation  of  the  neck  gradually  increases  as  pregnancy  advances, 
rendering  it  more  and  more  difficult  to  reach,  and  which  has,  probably, 
led  to  the  mistaken  views  of  several  authors,  that  the  cervix  became 
gradually  shortened  from  the  fifth  month  until  "term,"  at  which 
period  it  was  completely  effaced.  The  fact  is,  however,  that  there  is 
no  shortening  of  the  neck  until  the  ramollissement  has  occupied  its 
whole  extent,  rendering  it  yielding  and  incapable  of  resistance,  which 
generally  commences  in  the  last  fortnight  of  pregnancy,  and  during 
the  last  few  days,  both  in  primiparse  and  multipart,  and  then  in 
consequence  of  uterine  action  at  the  time  of  labor  (pressure  of  the 
bag  of  waters  and  of  the  fetal  head)  it  dilates,  shortens,  and  disappears, 
forming,  for  the  time  being,  a  part  of  the  uterine  sphere.  As  the 
neck  ascends,  looking  backward  and  to  the  left,  the  fundus  is  nearly 
always  carried  forward  and  to  the  right. 

Perhaps,  it  would  be  proper  to  remark,  that  in  primiparse,  toward 
the  seventh  month,  there  exists  a  slight  diminution  of  the  length 
of  the  cervix,  but  which  does  not  materially  affect  the  correctness 
of  the  above  statement ;  this  shortening  is  occasioned  by  the  spindle 
shape  assumed  by  the  cervix  at  this  period,  or  a  bulging  of  its 
central  part,  which  necessarily  causes  a  slight  approximation  of  the 


158 


KINO'S    ECLECTIC    OBSTETRICS. 


external  and  internal  orifices  of  the  neck.     This  does  not  happen  in 
multipart. 

The  form  of  the  cervix  is  different  in  primiparse  and  multipart, 
during  gestation.  Among  the  former  it  will  be  found  more  pointed 
and  contracted  at  its  inferior  extremity,  and  enlarged  at  its  superior, 
and  the  os  tincse  changes  from  a  hardly  perceptible  transverse  fissure, 
to  one  of  a  circular  form,  though  it  is  seldom,  if  ever,  opened,  until 
dilatation  occurs  during  labor.  About  the  seventh  month,  the  walls 
of  the  neck  having  become  softened,  they  readily  yield  to  the  pressure 
of  the  secretions  from  their  internal  surface,  and  as  the  os  tincse 
remains  closed,  the  central  portion  of  the  canal  of  the  cervix  is  pressed 
outward,  which  gives  to  the  whole  neck  a  fusiform  appearance.  The 
external  surface  remains  smooth  and  polished,  and  the  os  tineas 
regular  and  rounded,  without  any  roughness  or  inequalities ;  the 
circumference  is  sometimes  soft,  and  occasionally,  during  the  latter 
FIG.  43.  FIG.  44.  FIG.  45. 


These  Figures  show  the  softening  and  opening  of  the  cervix  uteri,  as  pregnancy  advances  ;  also,  how 
the  finger  ultimately  gets  into  direct  contact  with  the  naked  membranes. 

months,  presents  a  sharp  and  thin  border.  Among  multipart,  the 
form  of  the  cervix  is  quite  different,  somewhat  resembling  a  thimble, 
with  its  small  extremity  upward,  its  orifice  instead  of  being  closed  is 
opened  sufficiently  to  admit  the  extremity  of  the  finger,  and  its 
periphery  is  very  irregular  on  account  of  numerous  cicatrizations  and 
fissures,  the  results  of  previous  lacerations.  As  the  softening  advances 
upward,  the  opening  of  the  os  tinea?  and  inferior  portion  of  the  cavity 
of  the  neck  simultaneously  continues  to  increase,  so  that  each  month 
the  finger  may  penetrate  deeper  into  this  thimble-shaped,  and  some- 
times funnel-shaped  cavity.  Toward  the  ninth  month,  the  second 
phalanx  of  the  finger  can  be  introduced  within  this  opening,  its  free 
extremity  being  arrested  by  the  closed  and  puckered  ring  at  the  internal 
orifice,  which  finally  softens  and  dilates,  allowing  the  finger  to  pass 
through  the  cavity  of  the  neck,  and  to  come  in  direct  contact  with  the 
membranes.  At  this  period  the  canal  through  which  the  finger  passes, 


CHANGES   IN   THE   UTEEDS    DURING    PEEGNANCY.  159 

instead  of  being  shortened,  will  be  found  to  vary  from  one  inch,  to  an 
inch  and  a  half  in  length.  (Figs.  43,  44,  45.) 

The  softening  and  spreading  out  of  the  neck  is  said  to  be  greatly 
accelerated  by  frequent  touchings  or  examinations  .during  pregnancy, 
and  occasionally  the  internal  orifice  opens  at  too  early  a  period,  even 
in  the  seventh  month,  especially  among  those  women  who  are  subject 
to  floodings. 

It  is  sometimes  the  case,  that  the  presenting  part  of  the  fetus,  in 
engaging  in  the  excavation,  presses  the  anterior  inferior  portion  of  the 
uterus  before  it,  which,  in  a  large  pelvis,  may  even  descend  to  the  in- 
ferior floor,  occasioning  much  embarrassment  to  the  inexperienced 
practitioner,  who  not  being  able  to  ascertain  the  situation  of  the  os 
tincoe,  might  erroneously  suppose  it  to  be  imperforate.  It  will  be 
readily  seen  that,  as  the  portion  of  the  uterus  mentioned  is  pushed 
downward,  the  neck  will  be  carried  behind  it,  with  the  os  tincse  look- 
ing toward  the  anterior  face  of  the  sacrum,  and  much  difficulty  may 
be  experienced  in  gaining  access  to  it;  but  when  once  reached,  the 
finger  must  be  bent  like  a  hook  and  introduced  into  its  cavity  from 
behind  directly  forward,  pulling  the  neck  by  its  anterior  lip  down  to- 
ward its  normal  location  at  the  center  of  the  cavity,  while  at  the  same 
time,  efforts  may  be  made  with  the  other  hand  on  the  abdomen,  or  by 
means  of  an  assistant,  to  elevate  or  push  the  body  of  the  uterus  up- 
ward and  backward.  While  the  womb  remains  in  this  mal-position, 
it  will  be  impossible  for  delivery  to  be  accomplished  until  the  above 
change  in  its  direction  is  effected;  and  when  effected,  if  the  female 
has  been  long  in  labor,  with  evident  symptoms  of  dangerous  exhaust- 
ion, the  os  uteri  soft  and  dilated  or  dilatable,  and  the  head  at  the 
superior  strait,  my  own  experience  is  in  favor  of  at  once  terminating 
the  labor  by  turning  and  delivering  by  the  feet,  at  the  same  time 
administering  sufficient  stimuli  to  sustain  the  sinking  powers  of  the 
system.  This  is  the  course  I  have  adopted  in  three  instances  of  simi- 
lar character,  and  in  each  of  which  success  crowned  my  efforts,  with 
the  exception  of  one  child  being  still-born. 

PHYSICAL  CHANGES  IN  THE  BODY  OF  THE  UTERUS, 
etc.  In  the  non-gravid  state,  the  uterus  may  be  said  to  be  in  an  in- 
active or  dormant  condition,  from  which  it  is  suddenly  aroused  by 
conception,  and  becomes  more  susceptible,  with  increased  temperature 
and  swelling,  from  the  greater  sanguineous  determination  toward  it. 
The  volume  of  the  uterine  walls  increases  in  every  direction,  and  the 
uterine  cavity  enlarges,  which  enlargement  is  maintained  by  the  new 


160  KING'S    ECLECTIC    OBSTETRICS. 

formation  called  the  caducous  membrane,  and  which  is  present  long- 
before  the  impregnated  ovum  reaches  the  uterine  cavity.  As  soon  as 
the  ovule  has  reached  the  uterus,  the  increase  of  volume  or  develop- 
ment of  the  embryo,  continues  and  progresses  until  the  moment  of 
parturition,  being  more  rapid  in  the  latter  than  in  the  early  months. 

The  shape  of  the  uterus  is  not  materially  changed  during  the  first 
month  of  pregnancy,  but  subsequently,  as  its  volume  augments,  from 
being  flattened  from  before  backward,  it  gradually  grows  rounder, 
assumes  the  shape  of  a  pear,  or  gourd,  then  spheroidal,  until  toward 
the  termination  of  gestation,  it  becomes  of  an  ovoid  form,  slightly 
flattened  in  its  antero-.posterior  diameter,  with  its  anterior  face  more 
convex,  and  its  posterior  somewhat  concave,  to  adapt  itself  to  the  pro- 
jection of  the  lumbar  vertebrse. 

-  The  situation  of  the  uterus  must  necessarily  vary  in  proportion  to 
its  increasing  size  and  shape;  thus,  we  find  that  during  the  first  three 
months  of  pregnancy  it  is  lower  in  the  vagina,  or  pelvic  cavity,  with 
the  os  tincse  a  little  inclined  to  the  left,  and  thrown  forward  to  the 
pubis;  but  after  this  period  it  gradually  rises  from  the  excavation  into 
the  abdominal  cavity,  pushing  the  opposing  contents  of  this  cavity 
before  it.  From  a  knowledge  of  the  various  points  at  which  the 
fundus  is  located,  we  may,  by  palpation,  be  enabled  to  determine  the 
period  of  gestation;  thus,  at  the  fourth  month,  it  will  be  found  two  or 
three  fingers'  breadth  above  the  pubis ;  at  the  fifth  month,  it  will  be 
found  within  one  finger's  breadth  of  the  umbilicus;  the  hypogastrium 
projects  and  is  rounded,  the  vagina  is  elongated  and  narrowed,  and 
the  motions  of  the- fetus  are  felt;  the  cervix  is  more  elevated,  is  turned 
upwardly,  and  is  more  difficult  to  reach;  from  the  fifth  to  the  sixth 
month,  the  fundus  passes  the  umbilicus,  and,  at  the  sixth  month,  is 
found  half  an  inch  above  this  depression,  which  now  begins  to  project 
beyond  the  integuments ;  the  vagina  still  farther  elongated  and  nar- 
rowed, with  only  a  few  projecting  wrinkles  at  its  lower  portion ;  the 
cervix  will  be  found  nearly  on  a  level  with  the  superior  strait,  softer 
and  larger  than  previously ;  ballottement  is  now  readily  effected ;  at 
the  seventh  month  the  fundus  will  be  found  three  fingers'  breadth  above 
the  umbilicus,  with  increased  abdominal  and  umbilical  projection,  and 
often  pain  in  the  groins,  from  distension  of  the  muscles  of  the  ab- 
domen ;  the  neck  is  still  farther  softened,  more  voluminous,  and  more 
difficult  to  distinguish ;  at  the  eighth  month  the  fundus  extends  into 
the  epigastric  region,  the  abdomen  is  farther  distended,  and  the  skin 
frequently  cracks  and  presents  livid  marks  or  lines ;  the  ramollisse- 
ment,  or  softening  of  the  cervix  is  still  farther  advanced;  during  the 


CHANGES   IN   THE    UTERUS    DURING    PREGNANCY.  161 

ninth  month,  the  fundus  still  continues  to  ascend,  but  in  the  last  fort- 
night of  gestation,  there  is  an  evident  depression  of  the  abdominal 
projection,  the  fundus  is  on  a  lower  level  than  before;  the  respiration 
becomes  more  free,  the  woman  more  lively,  and  expresses  herself  as 
feeling  lighter;  the  cervix  is  entirely  softened.  This  sensation  of 
sinking  of  the  womb,  is,  probably  owing  to  descent  of  the  fetus,  the 
head  of  which  can  usually,  at  this  period,  be  readily  felt,  presenting  a 
voluminous  tumor  within  the  pelvic  excavation. 

Although  the  above  is  the  average  of  a  number  of  observations,  yet 
they  are  not  invariable ;  as,  in  many  females,  the  shape  and  capacity 
of  the  pelvis  and  abdomen,  and  the  resistance  of  the  abdominal  pari- 
etes,  will  affect,  more  or  less,  the  rapidity  and  extension  of  these 
changes. 

The  direction  of  the  uterus  is  altered  by  the  changes  which  take 
place  in  the  organ  during  pregnancy ;  while  it  remains  within  the  ex- 
cavation where  it  is  supported  by  the  pelvic  bones,  it  holds  its  vertical 
direction,  but  as  it  passes  upward  into  the  cavity  of  the  abdomen, 
where  the  soft  parts  alone  sustain  it,  it  inclines  forward,  following  the 
direction  of  the  axis  of  the  superior  strait,  and  which  may  be  owing 
to  the  unyielding  resistance  of  the  lumbar  prominence,  and  the  yield- 
ing of  the  anterior  abdominal  wall ;  from  the  same  cause  it  is  made  to 
lean  toward  one  side  of  the  abdomen,  most  commonly  the  right,  form- 
ing the  right  lateral  obliquity  of  the  uterus.  The  reason  of  the  greater 
frequency  of  this  right  obliquity,  is,  according  to  Mad.  Boivin,  that 
the  round  ligament  of  the  right  side  is  shorter,  stronger,  and  more 
abundantly  supplied  with  muscular  fibers  than  the  left ;  and  as  they 
draw  the  uterus  toward  the  right,  they  necessarily  cause  this  organ  to 
rotate  on  its  axis,  carrying  its  anterior  surface  somewhat  to  the  right 
side,  and  its  posterior  to  the  left ;  both  of  which  changes  are  import- 
ant to  be  understood. 

The  thickness  'of  the  uterine  parietes  has  given  rise  to  much  contra- 
dictory speculation ;  some  writers  concluding,  that  in  consequence  of 
the  great  distension  of  the  uterus,  its  walls  become  very  much  attenu- 
ated, while  others  consider  that  they  become  very  much  thicker  during 
pregnancy  ;  but  the  fact  is,  that  at  the  period  of  parturition,  if  an  ex- 
amination of  the  uterine  parietes  be  made,  they  will  be  found  to  vary 
according  to  the  portion  examined,  the  neck  being  very  thin,  and  the 
body  and  fundus  of  the  same  thickness  as  when  in  the  non-gravid 
condition,  with  the  exception  of  the  part  corresponding  to  the  inser- 
tion of  the  placenta,  which  is  thicker  than  at  any  other  place.  As 
there  is,  then,  no  diminution  of  the  uterine  walls  during  gestation, 


162  KING'S  ECLECTIC  OBSTETRICS. 

there  must  necessarily  be  a  great  augmentation  of  their  bulk,  which  ia 
ascri  taiiH-d  to  -be  the  case,  as  at  term,  the  uterus  has  been  found  to 
weigh  two  pounds ;  and  in  one  instance,  cited  by  M.  Moreau,  it  reached 
nearly  four  pounds.  In  a  few  rare  instances,  the  parietes  of  this  or- 
gan have  been  found  to  be  only  a  few  lines  in  thickness. 

The  density  of  the  uterine  parietes  likewise  changes  during  gestation. 
In  the  non-gravid  condition  they  are  hard,  resisting,  and  of  a  consist- 
ency approximating  fibrous  tissue,  but  in  pregnancy  they  become 
softer  and  relaxed,  which  condition  is  present  even  at  the  first  month, 
the  walls,  having  a  softness  which  gives  a  sensation  on  pressure,  simi- 
lar to  that  of  an  oedematous  limb,  or  of  caoutchouc  softened  by  boiling 
in  water,  and  which  is  of  some  value  in  determining  pregnancy.  As 
the  parturient  period  approaches,  this  ramollissement  and  yielding 
character  of  the  walls  continue  to  increase,  so  that  the  inequalities-of 
the  fetus  may  be  felt  through  them,  and  its  motions  may  not  only  be 
distinctly  perceived,  but  will  often  produce  a  momentary  projection  of 
some  part  of  the  organ,  and  even  of  the  abdominal  parietes.  In  con- 
sequence of  this  suppleness  of  the  uterine  fibers,  the  fetus  can  change 
its  position  within  the  cavity  of  the  organ  during  gestation,  and  thus 
cause  its  diameters  to  vary  according  to  the  position  assumed,  shorten- 
ing its  normal  long  diameter,  and  lengthening  its  short  ones.  The 
fetus  is  also  protected  from  the  evil  results  of  blows  upon  the  abdo- 
men, or  severe  shocks  received  by  the  mother,  which  would  ensue 
were  the  walls  more  dense  and  unyielding. 

VITAL  CHANGES  IN  THE  UTERINE  TISSUES.  The  most 
remarkable  changes  of  the  uterus,  during  pregnancy,  are  those  effected 
in  its  texture,  especially  that  of  its  proper  tissue,  or  middle  coat.  This 
tissue,  which,  as  I  have  heretofore  remarked,  is  of  a  grayish  color, 
dense,  and  composed  in  the  non-gravid  womb  of  minute  spindle-shaped 
fiber-cells,  with  elongated  oval  nuclei,  and  which  on  account  of  the 
great  quantity  of  nucleated  embryonic  connective  tissue,  can  be  isolated 
only  with  great  difficulty ;  during  pregnancy  these  muscular  fiber  cells 
become  enlarged,  their  length  being  increased  from  seven  to  eleven 
times,  and  their  width  from  two  to  five  times,  while  at  the  same  time 
new  ones  are  formed.  The  uterus,  in  pregnancy,  changes,  therefore, 
from  a  state  of  density  to  one  of 'softness  and  elasticity,  extending  its 
substance,  enlarging,  gradually  assuming  a  reddish  hue,  having  its 
fibers  gradually  unfolded,  elongated,  and  presenting  unequivocal  evi- 
dence of  its  muscular  nature. 

Although  the  muscular  character  of  the  middle  uterine  coat  has 


CHANGES    IN    THE   UTERUS    DURING    PREGNANCY.  163 

been  determined,  yet  the  arrangement  of  its  fibers  is  still  involved  in 
uncertainty.  Mad.  Boivin,  who  has  minutely  examined  the  uterine 
structure,  has  probably  given  us  the  most  correct  account  of  the  dis- 
position of  some  of  these  fibers ;  still,  there  is  much  left  to  ascertain 
on  this  point.  She  states,  that  there  is  an  exterior  plane  of  fibers, 
running  or  radiating  from  the  middle  line,  outward  and  downward,  to 
the  lower  third  of  the  womb;  upon  this  part  they  terminate,  and  aid 
in  forming  the  round  ligaments  located  there,  while  the  most  superior 
ones  are  distributed  to  the  Fallopian  tubes  and  the  ovarian  ligaments. 
There  is  also  an  internal  plane  of  fibers,  the  arrangement  of  which 
varies  considerably  from  the  external,  in  being  circular,  and  located  at 
the  uterine  superior  angle;  having  the  internal  orifice  of  the  tubes  as 
their  center,  they  surround  each  of  them,  describing  concentric  cir- 
cles, being  very  small  and  close  toward  the  focus,  but  gradually  sepa- 
ting  as  they  advance  from  this  point,  so  that  the  last  and  largest  are 
found  upon  the  median  line,  and  extend  in  the  direction  of  its  length. 
Other  muscular  fibers  are  found  between  these  two  planes,  but  they 
can  not  be  traced.  At  the  inferior  part  of  the  organ  is  a  semicircular 
order  of  fibers,  which  commence  at  the  median  line  of  this  region, 
and  reunite  on  the  sides  near  the  round  ligaments. 

"This  structure  of  the  uterus  resembles  that  of  all  hollow  organs, 
having  longitudinal  fibers  externally,  and  circular  and  horizontal  ones 
internally.  The  greatest  development  of  muscular  structure  is  found 
in  the  fundus,  which  is  part  of  the  organ  more  especially  concerned 
in  the  expulsion  of  its  contents,  and  this  structure  is  so  disposed  that, 
during  contraction,  the  uterine  surface  approaches  toward  the  center. 
The  least  resistance,  during  labor,  should  be  made  at  the  inferior  part 
of  the  uterus,  in  which  we  find  merely  the  horizontal  fibers,  form- 
ing an  arrangement  which  will  bear  some  comparison  to  a  sphincter 
muscle." 

Other  anatomists  have  attempted  to  trace  the  uterine  muscular  fibers, 
and  have  separated  them  into  layers,  planes,  and  fasciculi;  yet,  not- 
withstanding all  these  attempts,  there  is  so  much  irregularity  and  con- 
fusion in  the  course  and  arrangement  of  these  fibers,  so  many  cross- 
ings and  intercrossings,  and  such  an  interweaving  of  them,  that  it  is 
impossible  to  demonstrate  them  satisfactorily ;  we  have  presented  to 
us  only  an  inextricable  muscular  network,  rendering  the  uterus  fully 
capable  of  performing  all  its  various  movements  of  extension,  con- 
traction, dilatation,  and  shortening.  M.  Moreau  observe^that  "a  skill- 
ful dissector  may  give  the  fibers  any  direction  he  chooses,  without  the 
possibility  of  proving  the  contrary."  Farre  observes,  "  Nothing  like 


1(54  KING'S  ECLECTIC  OBSTETRICS. 

a  continuous  arrangement  of  muscular  fibers  in  the  form  of  circular  or 
longitudinal  bands,  surrounding  or  investing  the  organ  can  anywhere 
be  demonstrated  by  the  aid  of  the  microscope." 

That  the  longitudinal  and  horizontal  fibers  are  separate  and  inde- 
pendent parts  of  the  uterine  structure,  and  probably  all  the  other 
fibrous  arrangements,  may  be  inferred  from  the  fact,  that  we  often 
have  one  set  of  them  powerfully  acting,  while,  at  the  same  time,  the 
other  is  contracting  with  but  slight  force,  or  even  not  at  all.  Thus, 
in  the  hour-glass  contraction,  we  have  an  example  of  forcible  con- 
traction, and  a  want  of  it  at  the  two  antipodal  extremities.  Again, 
not  unfrequently  there  appears  to  be  a  want  of  action  o,f  those  fibers 
which  contract  the  organ  in  its  longitudinal  diameter,  elongating  the 
uterus  to  such  an  extent,  that,  as  ascertained  by  an  examination  through 
the  relaxed  abdominal  walls,  after  delivery,  its  length  will  be  ten  or 
eleven  inches,  with  the  fundus  elevated  toward  the  epigastrium,  wrhile 
its  transverse  diameter  will  be  only  three  or  four  inches,  resembling 
an  intestine,  rather  than  the  womb. 

A  female  during  labor,  as  is  often  the  case,  may  suffer  intense  pains, 
and  make  the  most  vigorous  efforts,  without  any  advance,  whatever, 
of  the  child,  although  the  pelvic  formation  is  normal,  and  the  uterus 
sufficiently  dilated ;  may  this  not  be  owing  to  a  want  of  simultaneous 
action  of  the  two  separate  sets  of  fibers,  the  horizontal  being  active, 
while  the  longitudinal  are  slightly  so,  or  altogether  inert?  This  want 
of  synchronism  in  the  movements  of  the  fibers,  may  be  owing  to  irri- 
tation occasioned  by  protracted  or  severe  labor,  by  rheumatism,  by  the 
administration  of  ergot,  or  by  officious  intermeddlings,  and  which  may 
also  result  from  extreme  susceptibility  of  the  nervous  system.  Gel- 
semium  will  be  the  remedy  if  the  irritation  has  developed  spasmodic 
action ;  or  Lobelia,  by  relaxation,  may  overcome  the  irregular  action 
in  the  two  sets  of  muscular  fibers.  If  the  condition  depends  upon 
rheumatism,  think  of  Macrotys.  In  either  case,  to  relieve  this  painful 
condition,  the  internal  use  of  Opium,  Morphia,  or  Diaphoretic  pow- 
der, may  be  given  as  often  as  the  urgency  of  the  symptoms  indicate; 
the  room  must  be  freely  ventilated,  the  drinks  should  be  cool,  and  no 
examinations  per  vaginam  must  be  instituted  until  the  contractions 
become  normal,  and  not  then,  without  they  are  actually  necessary. 
Occasionally,  under  these  circumstances,  and  where  there  have  been 
no  previous  violent  contractions,  in  addition  to  the  above  treatment, 
I  have  found  firm,  but  moderate,  pressure  over  the  fundus  to  restore 
the  energy  of  the  inactive  fibers. 

The  serous,  or  external  peritoneal  coat  of  the  uterus,  during  preg- 
nancy, extends  in. every  direction,  with  a  more  active  nutrition  that 


CHANGES    IX    THE    UTERUS    DURING    PREGNANCY.  165 

prevents  any  diminution  of  its  depth,  there  being  but  little  difference 
in  the  thickness  of  this  external  covering,  either  in  the  gravid  or  non- 
gravid  womb.  The  serous  covering  is  movable  on  the  tissue  which 
unites  it  to  the  middle  or  muscular  coat,  this  tissue  being  apparently 
diminished  in  density. 

The  internal,  or  mucous  coat  of  the  uterus,  about  which  there  have 
been  so  many  discordant  opinions,  becomes  very  evident  during  preg- 
nancy ;  it  is  softer,  more  lax,  and  redder,  is  more  distinctly  denned 
from  the  muscular  coat,  its  vessels  become  more  distended ;  and  be- 
coming hypertrophied,  it  presents  an  increased  and  villous  appear- 
ance, and  from  its  great  development  its  nutrition  undoubtedly  be- 
comes more  active.  Its  follicles  become  more  marked,  with  an  increase 
of  their  secretion.  There  are  also  glands  found  imbedded  in  the 
thickness  of  this  coat,  which  appear  to  enter  into  the  internal  mus- 
cular layers;  these  enlarge  after  conception,  and  are  viewed  by  some 
authors  as  the  principal  elements  of  the  caducous  or  nidal  membrane. 
These  glands  resemble  small  canals,  and  run  tortuously  within  and 
behind  the  mucous  uterine  coat,  forming  a  kind  of  knot,  throwing  out 
ramifications,  and  opening  on  the  internal  face  of  the  inner  mucous 
layer :  they  have  been  called  the  utricular  glands. 

The  blood-vessels  of  the  uterus  likewise  undergo  changes  which  may 
be  briefly  noticed.  In  the  unimpregnated  condition  the  arteries  are 
small,  flexuous,  and  very  much  contracted,  but  during  gestation,  as 
they  become  less  compressed  by  the  uterine  fibers,  they  expand,  soften, 
and  describe  more  regular  curves ;  their  caliber  increases,  the  blood 
circulates  more  largely  and  rapidly,  and  a  more  active  and  energetic 
nutrition  ensues.  The  arteries  of  the  uterus,  as  heretofore  stated,  are 
furnished  by  the  spermatics  and  hypogastrics,  the  superior  portion  of 
the  uterus  receiving  chiefly  the  branches  from  the  spermatics,  and  the 
body  and  cervix  those  only  from  the  hypogastrics.  The  arteries  are 
always  tortuous,  and  when  they  arrive  at  the  uterus,  they  do  not  run 
any  distance  under  the  peritoneum,  but  immediately  enter  into  the 
muscular  coat,  pass  toward  the  inner  surface,  and  especially  to  the  part 
where  the  placenta  is  attached,  ramifying  and  anastomosing  freely  as 
they  proceed;  those  branches  which  reach  the  lining  membrane  ter- 
minate in  the  tortuous  canals  in  the  placental  decidua,  while  those 
which  do  not  arrive  at  the  inner  surface  ramify  upon  the  coats  of  the 
veins.  The  veins  of  the  uterus  are  greatly  dilated,  much  more  so 
than  the  arteries,  and  their  points  of  communication  with  each  other 
are  multiplied  to  that  degree,  that  at  the  parturient  term,  an  inextrica- 
ble mass  of  venous  vessels  is  presented,  giving  to  the  uterine  tissue  a 
resemblance  to  that  of  the  erectile.  That  part  of  the  uterus  to  which 


KINC'S    i;ru:<Tir  OIISTKTUICS. 

the  placenta  is  attached  IB  more  abundantly  supplied  with  veins;  and 
on  removing  the  placenta,  the  veins  which  open  into  the  uterine  cavity 
will  be  seen,  presenting  large,  smooth-edged  and  oblique  apertures. 
There  are  no  proper  valves  to  the  veins,  so  that  if  any  fluid  be  injected 
into  the  trunks  of  the  spermatic  and  hypogastric  veins,  it  will  flow  in 
a  full  stream  into  the  cavity  of  the  uterus,  which  may  afford  some  ex- 
planation of  the  cause  of  the  large  quantity  of  blood  discharged  in  so 
short  a  time  from  the  uterus  during  parturition,  together  with  that 
from  the  exposed  arteries.  The  venous  circulation  in  the  uterus  and 
placenta  may  be  readily  interrupted  by  the  various  derangements  of 
function  in  the  thoracic  and  abdominal  viscera,  and  the  removal  of 
these  obstructions  during  pregnancy  is  an  important  point. 

The  lymphatic  vessels,  or  absorbents,  likewise,  become  greatly  en- 
larged during  pregnancy:  according  to  Cruikshank,  the  first  who 
observed  them,  they  are  as  large  as  a  goosequill,  and  are  so  numerous, 
that  when  injected  with  mercury,  they  give  to  the  uterus  the  appear- 
ance of  a  mass  of  lymphatic  vessels.  Those  of  the  neck  run  into  the 
pelvic  ganglia,  and  those  of  the  body  into  the  lumbar  ganglia.  Cruik- 
shank supposed  their  function  to  be  that  of  carrying  on  a  "  copious 
absorption  in  the  uterus  toward  the  mother,"  during  pregnancy;  but 
Dr.  Eobert  Lee  has  suggested  another  very  probable  function ;  he  ob- 
serves, "The  sudden  removal  of  the  uterine  structures  after  delivery 
by  absorption,  is  probably  the  most  important 'office  they  perform,  and 
the  cause  of  their  enlargement  to  such  a  vast  size  during  the  latter 
months  of  pregnancy." 

The  nerves  of  the  uterus  likewise  become  considerably  developed 
during  gestation,  for  the  undoubted  purpose  of  furnishing  the  uterus, 
during  the  parturient  act,  with  all  the  nervous  energy  that  may  be 
necessary.  After  delivery,  the  nerves,  together  with  all  the  augmented 
tissues  and  vessels  of  the  uterus,  return  to  their  original  size  and 
condition. 

CHANGES  IN  THE  PROPERTIES  OF  THE  UTERUS.     In 

the  unimpregnated  condition,  the  vital  properties  of  the  uterus  are 
very  obscure,  so  that  it  may  be  touched,  compressed,  pricked,  or  even 
cauterized  without  causing  pain  or  much  uneasiness,  unless  it  be  mor- 
bidly affected;  at  this  time  its  properties  are  chiefly  limited  to  its  tonic 
forces,  or  organic  sensibility  and  insensible  contractility,  the  separa- 
tion of  the  principles  of  growth  and  nutrition  from  the  circulating 
fluids,  and  the  elimination  of  de-vitalized  or  decomposed  elements 
which  are  no  longer  necessary  to  the  maintenance  of  life. 


CHANGES    IN    THE    UTERUS    DURING    PREGNANCY.  167 

It  is  true,  that  when  the  finger  is  brought  into  contact  with  the 
neck,  the  female  is  conscious  of  the  touch ;  however,  the  sensation  goes 
no  farther ;  but  during  pregnancy  the  animal  sensibility  becomes  much 
more  marked,  and  the  female  more  readily  recognizes  the  contact  of 
bodies  with  the  neck,  as  well  as  the  fetal  movements,  and  which  sensi- 
bility becomes  more  developed  as  gestation  advances,  so  that  in  its 
latter  stages  even  the  touch  becomes  excessively  painful  with  many 
women,  and  during  parturition  the  uterine  contractions  produce  intense 
agony.  The  introduction  of  the  hand  within  the  uterus,  for  the  pur- 
pose of  turning,  effects  similar  pain,  and  when  the  adhering  placenta 
is  removed  artifically,  the  woman  experiences  sensations  as  if  she  were 
being  eviscerated.  This  exaltation  of  animal  sensibility  is  principally 
confined  to  the  neck,  the  body  of  the  organ  being  nearly  insensible ;  there 
exists,  however,  a  relation  between  these  two  parts,  from  which  irrita- 
tion of  the  neck  will  influence  the  fibers  of  the  body.  And  this 
relation  will  account  for  the  premature  births  effected  by  repeated 
touchings,  frequent  coition,  the  irritations  of  the  cervix  from  artificial 
dilatation,  or  the  use  of  agents  which  stimulate  the  cerebro-spinal  sys- 
tem. It  occasionally  happens,  that  the  female  will  be  unconscious  of 
any  movements  of  the  fetus  until  the  latter  months  of  gestation,  or 
even  not  until  labor  actually  commences,  owing  to  the  slight  develop- 
ment of  sensibility,  but  in  the  majority  of  cases  it  is  the  very  reverse 
of  this. 

The  most  remarkable  property,  however,  which  the  uterus  manifests 
during  pregnancy  is  its  organic  contractility,  which  either  did  not  pre- 
viously exist,  or  if  it  did,  it  remained  latent.  This  property,  precisely 
resembles  the  contraction  of  a  muscle,  and  is  never  manifested  except 
under  some  irritating  or  stimulating  influence ;  it  varies  in  intensity 
in  different  females,  and  is  so  marked  and  energetic  in  many  instances 
as  to  benumb  the  hand  of  the  strongest  man,  when  introduced  to  per- 
form artificial  delivery.  It  is  this  contractile  power  which  effects  the 
expulsion  of  the  fetus  and  its  secundines,  as  well  as  other  productions 
which  may  be  accidentally  developed  within  the  uterine  cavity,  and 
which,  likewise,  causes  the  womb,  as  well  as  its  various  vessels,  to 
gradually  return  to  the  diminished  condition  in  which  they  were  pre 
vious  to  conception.  Should  the  organic  contractility  of  the  uterus, 
from  any  cause,  fail  to  manifest  itself  after  parturition,  a  hemorrhage 
would  ensue  that  would  prove  rapidly  fatal  to  the  parturient  woman  ; 
and,  when  such  cases  occur  in  practice,  the  most  important  indication 
is  to  arouse  this  power  of  contraction,  which  is  the  natural  remedy, 
and  which  produces  its  beneficial  results  by  closing  and  obliterating 


168  KING'S  ECLECTIC  OHSTETRICS. 

the  large  open  mouths  of  the  blood-vessels  on  the  internal  placental 
surface  of  the  organ. 

In  the  human  family  the  presence  of  these  contractions  is  always 
accompanied  with  more  or  less  pain,  which  is  never  found  among  ani- 
mals in  a  state  of  nature,  and  which  exists  among  savages  and  domes- 
ticated animals  in  only  a  minor  degree.  Accident  or  disease  may, 
however,  be  the  cause  of  pain  with  these  last  when  in  labor;  and  we 
have  good  reasons  for  believing  that  the  excessive  pains  undergone  by 
parturient  females  of  our  own  race,  are  the  results  of  the  enervating 
influence  of  civilization  and  its  various  customs,  habits,  and  refine- 
ments upon  the  constitution.  In  1842,  I  was  called  upon  to  attend 
Mrs.  D ,  about  twenty  years  of  age,  a  short,  thick-set  female,  bru- 
nette, and  in  apparent  good  health,  with  her  first  child;  there  had 
been  observed  a  discharge  of  the  waters,  "  the  show,"  together  with 
some  singular  and  indescribable  feelings,  but  no  pain.  From  these 
symptoms,  together  with  the  calculations  made  upon  the  matter,  it  was 
presumed  that  labor  could  not  be  far  distant ;  and  it  was,  likewise, 
deemed  expedient  by  the  mother  that  the  advice  of  a  physician  should 
be  resorted  to.  Having  ascertained  that  no  pains  of  any  kind  had 
been  experienced,  I  thought  myself  unwarranted  in  making  any  ex- 
amination, but  did  so  at  the  urgent  request  of  the  mother,  when  to  my 
great  astonishment  I  found  the  head  within  the  pelvic  cavity,  and  upon 
placing  my  hand  upon  the  abdomen,  I  felt  very  distinctly  the  con- 
tractions of  the  uterus  as  they  occurred,  but  the  patient  complained  of 
no  pain  whatever.  I  now  seated  myself  by  the  bedside  to  watch  the 
progress  of  labor,  as  well  as  to  be  ready  for  any  emergency  in  so  sin- 
gular a  case,  and  the  whole  process  of  parturition  was  effected  without 
any  untoward  accident,  and  without  the  least  pain,  if  the  asseverations 
of  the  female  are  to  be  believed;  during  the  latter  stage  she  evidently 
contracted  the  abdominal  muscles  and  made  bearing  down  efforts,  not, 
she  stated,  from  any  painful  influences,  but  from  a  strong  sensation  or 
desire  to  make  them.  Shortly  previous  to  my  visiting  the  West,  I 
again  attended  this  lady  in  her  second  labor,  when  she  suffered  as  se- 
vere pains  as  I  remember  to  have  ever  witnessed  in  the  parturient 
chamber.  The  cause  of  this  anomaly  I  do  not  pretend  to  understand. 
The  female,  as  a  rule,  suffers  more  severely  with  the  pains  in  her  first 
labor,  than  in  subsequent  ones;  however,  there  is  no  law  governing 
this  matter  so  far  as  individuals  are  concerned :  each  accouchment  of 
the  same  woman  is  peculiar  unto  itself.  In  prognosing  the  probable 
outcome  of  a  labor,  the  practitioner  should  not  be  influenced  by  for- 


CHANGES    IN    THE    UTERUS    DURING    PREGNANCY.  169 

mer  experiences  with  the  same  person.  As  in  the  case  cited,  the  con- 
dition of  the  woman  may  be  so  favorable,  that  delivery  will  be  accom- 
plished and  she -scarcely  experience  any  uneasiness  whatever,  and  but 
very  slightly  the  pains  peculiar  to  labor,  while  her  next  lying-in  may 
be  characterized  by  the  most  severe  pains,  and  suffering  so  intense  as 
to  demand  relief  by  the  administration  of  remedies,  in  some  cases  ne- 
cessitating the  effect  of  an  anaesthetic. 

The  exercise  of  these  organic  contractions  ensues  involuntarily  and 
without  any  dependence  on  the  will,  yet  we  sometimes  find  them  in- 
fluenced by  mental  impressions,  so  much  so,  that  a  violent  emotion 
may  arouse  them  at  a  premature  period,  and  it  is  not  an  uncommon 
circumstance  for  the  appearance  of  the  accoucheur  in  the  room  of  the 
lying-in  woman  to  cause  a  suspension  of  them  for  several  hours,  or 
even  days.  They  may  likewise  be  suspended  for  some  hours  by  the 
administration  of  opiates,  as  well  as  excited  by  stimulants,  or  irritation 
applied  to  the  neck,  or,  ergot,  strychnia,  electricity,  borax,  and  many 
other  agents  internally  administered.  If  the  uterus  is  excessively 
distended — if  the  labor  has  been  too  rapid,  or  prolonged — the  con- 
tractions are  very  apt  to  diminish — become  more  slow  and  feeble,  or 
entirely  cease.  I  have  met  with  instances,  in  which  the  contractions 
have  been  suspended  for  several  hours,  in  consequence  of  an  intoxi- 
cating draught  of  hot  gin  or  brandy  sling  having  been  given  by  the 
nurse,  to  "ease  the  pains  and  give  the  woman  strength." 

These  changes  in  the  condition  of  the  uterus,  necessarily  effect  some 
modifications  of  the  neighboring  parts.  In  the  early  period  of  preg- 
nancy, as  the  uterus  enlarges  in  the  cavity,  the  vagina  becomes  short-i 
ened,  but  as  soon  as  the  former  rises  above  the  superior  strait,  the 
latter  becomes  narrower  and  longer;  in  its  elevation  the  uterus  carries 
its  surrounding  peritoneum  along  with  it,  the  folds  of  which,  or  the 
broad  ligaments,  disappear,  and  the  tubes  and  ovaries  approach  nearer 
to  the  uterus,  where  they  rest,  nearly  in  a  perpendicular  position;  the 
round  ligaments  present  short  linear  fibers,  among  which  are  prolonga- 
tions of  the  muscular  fibers  of  the  uterus,  and  which  contract  with 
that  organ. 

From  the  increased  vitality  of  the  re-productive  organs,  as  well  as 
from  the  obstruction  of  circulation  by  the  enlarged  uterus,  the  veins 
of  the  vaginal  walls  become  more  developed,  with  various  appearances, 
which  are  often  recognized,  toward  the  termination  of  gestation,  by  the 
finger.  The  vaginal  pulse,  of  Osiander,  which  he  estimated  highly  as 
a  diagnostic  sign  of  pregnancy,  may  be  felt,  at  some  portion  of  the 


170  KING'S  ECLECTIC  OBSTETRICS. 

vagina,  and  is  owing  to  the  excessive  enlargement  of  the  vaginal  and 
uterine  arteries.  About  the  seventh  or  eighth  month,  the  vaginal 
mucous  membrane  is  frequently  covered  with  granulations  the  size  of 
a  pin's  head,  which  not  only  line  the  whole  extent  of  this  canal,  but 
also  the  exterior  surface  of  the  neck,  and  even  the  interior.  When 
these  are  present,  there  is  an  increased  vaginal  secretion. 

One  of  the  important  changes  to  be  understood  by  the  practitioner, 
is  that  undergone  by  the  bladder.  This  organ  is  gradually  pressed 
above  the  superior  strait,  the  urethra]  canal  is  elongated,  and  its  orifice 
will  be  found  behind  the  edge  of  the  pubic  symphysis,  so  that  in  intro- 
ducing a  catheter  it  must  be  directed  nearly  if  not  quite  parallel  with 
the  pubic  bone,  with  its  concavity  in  front,  and,  in  some  instances,  the 
curve  of  the  canal  becomes  so  great,  from  the  bladder  being  pressed 
forward  and  above  the  pubis,  that  a  male  catheter  will  be  introduced 
with  more  facility.  This  compression  on  the  upper  part  of  the  canal, 
impedes  the  circulation  in  the  lower  parts,  from  which  results  tume- 
faction of  its  whole  length.  Tenesmus  of  the  bladder  is  often  the 
consequence  of  compression  on  the  body  and  neck  of  this  organ,  occa- 
sioning frequent,  urgent,  and  ineffectual  efforts  to  urinate.  In  not  a 
few  instances  the  catheter  will  have  to  be  used  to  relieve  the  irritated 
and  distended  bladder. 


OF    PREGNANCY.  171 


CHAPTER    XVIII. 

OF    PREGNANCY. 

WHEN  the  fecundated  ovum  becomes  attached  to  some  portun  of 
the  uterus,  conception  is  said  to  have  taken  place,  and  the  peculiar 
condition  of  the  woman,  from  the  moment  of  conception  to  the  period 
of  parturition,  is  called  pregnancy  or  utero-gestation ;  this  usually  com- 
prises nine  calendar  months,  or  two  hundred  and  eighty  days  from  the 
last  menstrual  show,  or  one  hundred  and  forty  days  after  quickening — 
the  time  at  which  most  females  perceive  the  first  motions  of  the  fetus, 
and  which  generally  occurs  about  the  twentieth  week  after  conception. 
Although  this  is  the  period  which  seems  to  have  been  generally 
recognized  from  the  earliest  ages,  yet  it  is  not  invariable,  as  it  occa- 
sionally terminates  sooner,  and  again,  may  extend  to  even  ten  months, 
of  which  there  are  well  attested  cases  on  record.  The  determination 
of  this  subject  is  one  of  great  difficulty,  as  we  can  seldom  ascertain  the 
precise  moment  of  fecundation,  and  yet  it  is  one  of  immense  import- 
ance, from  the  fact  that  the  legitimacy  of  the  oifspring  may  depend 
upon  a  correct  decision. 

The  only  method  by  which  we  can  ascertain  the  commencement  of 
utero-gestation,  is  by  reference  to  the  period  of  the  last  menstrual 
flow,  as  well  as  to  the  time  of  quickening;  but  even  these  means  are 
very  uncertain,  as  conception  may  occur  sometime  during  the  inter- 
menstrual  period;  beside  which,  the  period  of  quickening  varies  in 
different  women.  On  account  of  these  difficulties,  laws  have  been 
established  in  several  nations,  fixing  the  term  within  which  legitimacy 
is  acknowledged  by  them;  thus,  in  France,  the  "Code  Napoleon," 
admits  the  legitimacy  of  a  child  born  within  three  hundred  days  after 
wedlock,  divorce,  or  death  of  the  husband;  and  if  born  after  that 
time,  its  legitimacy  may  be  contested,  though  it  is  not  to  be  viewed 
as  a  bastard.  In  Prussia,  three  weeks  beyond  the  usual  time  are 
allowed,  or  three  hundred  and  one  days.  In  Scotland,  ten  calendar 


172  KIND'S    KCLECTIC    OBSTETRICS. 

months  are  considered  the  extent  of  legitimacy.  In  England  and  in 
this  country,  the  limit  of  gestation  is  not  determined  by  law. 

That  the  term  of  utero-gestation  varies  in  many  females  is,  I 
believe,  generally  admitted  by  observing  accoucheurs  of  the  present 
day,  and  the  existence  of  the  laws  on  this  subject,  in  the  countries 
above  referred  to,  are  strong  confirmations  of  the  possibility  of  pro- 
tracted gestation.  Indeed,  I  have  met  with  several  instances  in  which 
I  had  every  reason  for  believing  that  the  pregnancy  had  been  pro- 
longed to  two  and  three  weeks  beyond  the  usual  period ;  and  two,  in 
particular,  in  which  I  positively  know  that  gestation  was  continued 
for  ten  months.  Drs.  Blundell,  Desormeaux,  Hunter,  Montgomery, 
Rigby,  Hamilton,  Burns,  Dewees,  Velpeau,  Merriman,  Moreau,  Simp- 
son, Meigs,  Atlee,  and  many  others,  have  met  with  similar  instance:?, 
in  which  the  term  of  gestation  had  extended  from  one  to  four  weeks 
beyond  nine  calendar  months.  Their  reported  cases,  taken  in  con- 
nection with  investigations  made  on  animals,  as  rabbits,  sheep,  cows, 
mares,  etc.,  that  likewise  are  found  to  vary  considerably  in  their 
periods  of  gestation,  certainly  aiford  the  strongest  evidence  in  favor 
of  prolonged  pregnancy.  Eelative  to  this  subject,  Dr.  Montgomery 
justly  observes :  "  We  can  not  imagine  why  gestation  should  be  the 
only  process  connected  with  reproduction,  for  which  a  total  exemption 
from  any  variation  in  its  period  should  be  claimed.  The  periods  of 
menstruation  are,  in  general,  very  regular ;  but  who  is  there  who  does 
not  know,  that  as  there  are,  on  the  one  hand,  women  in  whom  the 
return  of  that  discharge  is  anticipated  by  several  days,  so  there  are 
also  many  in  whom  the  return  is  postponed  an  equal  length  of  time, 
without  the  slightest  appreciable  derangement  of  the  health.  Again, 
menstruation  and  the  power  of  reproduction  in  the  female,  very  gen- 
erally, indeed  almost  universally,  ceases  about  the  forty-fifth  year,  in 
these  countries ;  yet  occasionally  instances  are  met  with,  in  which  both 
are  prolonged  ten  or  fifteen  years  beyond  that  time  of  life ;  and  a 
similar  variety  is  observable,  in  the  period  of  the  first  establishment  of 
that  function  in  the  system.  If  we  turn  our  attention  to  brutes,  the  con- 
ditions of  whose  gestation  so  closely  coincide  with  those  of  the  human 
female,  and  are  less  disposed  to  have  it  disturbed,  we  can  not  Tor  a 
moment  doubt  the  fact,  that  there  is  a  great  irregularity  in  the  term 
of  gestation  in  different  individuals  of  the  same  species." 

Dr.  Charles  Clay,  of  England,  has  advanced  the  view  that  the  term  of 
utero-gestation  is  regulated  by  the  ages  of  the  individuals  concerned  in 
the  act;  that  the  younger  these  individuals  the  shorter  the  term,  and,  as 


OF    PREGNANCY. 


173 


age  advances,  the  period  of  gestation  is  proportionately  lengthened. 
From  what  he  has  been  enabled  to  glean,  the  term  of  gestation  has 
occurred  as  follows : 


....  264  days 

274  davi 

«  15        "    "   

....  267  " 

"  30   "    "   

276  " 

"  15  to  15J   "    "   

.....  267  " 

"  35   "    «   

278  " 

"  15  to  17   "    "   

....  270  " 

"  44   "    "  

«»84  " 

'(  19        «    «   

....  272  " 

«  52   "    "  

290  " 

But,  he  observes,  the  age  must  be  calculated  not  by  that  of  the 
mother  alone,  but  by  the  combined  ages  of  both  parents.  Thus,  if 
the  female  be  twenty,  and  the  male  thirty,  a  result  must  be  expected 
equal  to  an  age  of  twenty-five,  or,  taking  into  consideration  the  earlier 
maturity  of  the  female,  of  twenty-four.  If,  however,  the  female  be 
thirty,  and  the  male  twenty,  then  the  result  would  equal  an  age  of 
twenty-six.  For  the  extension  of  inquiry  on  this  subject,  he  remarks: 
"  It  will  be  desirable  in  all  cases  to  be  recorded,  whether  in  favor 
or  against  the  propositions  here  laid  down,  to  secure  the  following 
data :  1st.  Date  of  conception  arising  from  a  single  contact.  2d.  Date 
of  parturition  commencing.  3d.  Age  of  the  mother.  4th.  Age  of 
the  father.  5th.  In  statements  of  age,  where  the  female  is  the 
younger,  it  must  be  fixed  at  the  year  below  the  mean  ages  of  the 
two  combined.  6th.  Where  the  female  is  the  older,  the  age  must 
be  fixed  a  year  above  the  mean  of  the  two  combined;  by  this  rule 
the  average  age  on  the  [above]  table  will  give  the  days  of  gestation 
more  correctly  than  by  any  other  known  rule."  (The  Complete  Hand- 
book of  Obstetrics,  Surgery,  etc.,  by  Charles  Clay,  M.  D.)  This  hy- 
pothesis of  Dr.  Clay's  does  really  appear  to  be  supported  by  the  data 
he  advances,  and  is  certainly  deserving  more  thorough  investigation. 

I  will  give  here  a  table  which  will  be  found  useful  for  determining 
the  period  at  which  menstruation,  quickening,  parturition,  etc.,  may 
probably  occur.  This  table  is  so  arranged  that  the  dates  on  the 
same  line  in  the  several  columns  are  consecutively  twenty-eight  days 
or  one  lunar  month  distant  from  each  other.  Thus,  if  a  female 
menstruates  on  the  7th  January,  her  next  period  will  occur  twenty- 
eight  days  subsequently,  on  the  4th  February,  the  next  on  the  4th 
March,  then  1st  April,  and  so  on. 

Pregnancy  is  usually  dated  from  the  last  menstruation,  on  account 
of  the  difficulty  of  determining  the  precise  period  of  a  fruitful  coitus  j 


174 


KING'S    ECLECTIC    OBSTETRICS. 


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OF   PBEGNANCY.  175 

two  hundred  and  eighty  days  after  the  last  menstruation  is  the  usual 
period  allowed  for  full  term  of  pregnancy ;  or  two  hundred  and 
seventy-five  days  from  a  fruitful  coitus  when  this  is  known.  Hence, 
five  days  may  be  allowed  in  the  calculation  with  the  accompanying 
table;  thus,  if  a  pregnant  female  had  her  last  menstruation  on  29th 
July  of  any  year,  her  period  of  confinement  will  occur  at  about  two 
hundred  and  eighty  days,  or  ten  lunar  months  subsequently,  which, 
upon  counting,  we  find  will  be  on  the  8th  April  of  the  ensuing  year; 
or  by  allowing  five  days,  we  may  expect  her  labor  to  come  on  between 
the  8th  and  13th  of  April. 

Quickening  is  generally  supposed  to  be  first  experienced  at  about 
the  one  hundred  and  fortieth  day  of  pregnancy ;  hence,  if  a  female 
perceives  quickening  for  the  first  time  on  llth  August,  by  count- 
ing along  in  the  table  for  the  balance  of  the  period  of  pregnancy,  that 
is,  one  hundred  and  forty  days,  or  five  lunar  months,  we  find  that 
labor  will  probably  occur  upon  or  about  the  ensuing  29th  December. 
I  say,  probably,  because  there  is  less  certainty  in  this,  as  quickening 
may  be  perceived  at  a  much  earlier  period,  or,  at  a  more  advanced 
stage  of  the  pregnancy. 

.After  December,  the  present  year  in  question  terminates,  so  that, 
upon  finding  on  what  day  in  January,  in  the  last  or  fourteenth  column, 
the  counting  along  on  the  same  line  terminates,  and  it  is  necessary  to 
count  on  still  farther,  we  must  return  to  the  same  date  of  January  in 
the  first  column,  as  we  left  in  the  last  or  fourteenth  column,  and  then 
count  along  on  the  corresponding  line  as  far  as  may  be  required. 
Thus,  if  we  desire  to  count  nine  lunar  months  from  1 8th  October,  we 
find  that  three  lunar  months  brings  us  to  10th  January  of  the  next 
year  in  the  last  or  fourteenth  column — we  now  find  the  10th  January 
in  the  first  column,  and  by  counting  along  for  the  balance  of  the  time, 
six  lunar  months,  it  brings  us  to  the  27th  June  of  the  subsequent  year. 

In  leap  year  one  day  may  be  deducted  from  the  ascertained  period, 
after  having  passed  the  month  of  February  of  the  leap  year ;  thus,  two 
hundred  and  eighty  days  from  19th  November  would  be  26th  August 
of  the  ensuing  year — but,  if  this  be  a  leap  year,  it  will  be  25th  August  ; 
again,  two  hundred  and  eighty  days  from  13th  August  would  be 
20th  May  of  the  next  year,  or,  if  le.ap  year,  19th  May. 

By  reference  to  the  figures  at  the  bottom  of  each  column,  counting 
from  the  first  column,  we  can  always  determine  how  many  lunar 
months  or  columns  must  be  included  within  any  number  of  days,  and 
vice  versa.  Thus,  six  lunar  months  or  columns  are  equal  to  one 
hundred  and  sixty-eight  days — then  one  hundred  and  sixty-eight  days 


176  KING'S  ECLECTIC-  OBSTETRICS. 

from  the  18th  July  would  be  six  columns  or  lunar  months,  carrying 
us  to  2nd  January  of  the  next  year.  The  reader  may  find  various 
other  uses  for  this  table. 

Another  point  to  determine,  is  the  earliest  period  at  which  a  child 
may  be  born,  consistent  with  its  existence  subsequently.  This  is  like- 
wise a  subject  of  much  moment,  involving  the  reputation  of  a  mother, 
the  legitimacy  of  oifspring,  and  the  peace  and  happiness  of  families, 
especially  in  those  instances  where  the  fetal  developments  exceed  those 
which  are  generally  found  at  the  various  periods  of  pregnancy.  I 
remember  an  incident  which  occurred  some  years  since,  and  which 
I  will  relate  here,  to  show  the  importance  of  prudence.  I  was  called 
to  attend  a  lady  who  had  aborted  three  months  after  her  marriage: 
the  fetus  presented  all  the  appearances  of  one  between  the  fourth  and 
fifth  months,  and  on  seeing  it,  I  innocently  remarked,  "  it  is  a  good- 
sized  one."  This  imprudent  remark  occasioned  much  unhappiness  in 
the  minds  of  the  husband,  the  mother  of  the  lady,  and  herself;  and 
they  each  inquired  of  me,  in  private,  if  I  supposed  there  "was  any- 
thing wrong?" — having  reference  to  the  wife's  chastity.  I  had  long 
known  each  of  the  parties,  before  their  marriage,  and  had  no  reasons 
whatever  for  the  most  distant  idea  of  want  of  purity  and  virtue,  and 
it  was  from  this  consciousness  of  undoubted  integrity  of  character 
that  the  observation  was  inadvertently  made — and  I  so  replied  to  their 
inquiries.  About  eighteen  or  nineteen  months  afterward,  I  delivered 
this  lady  of  a  male  child,  at  full  term,  which  having  been  weighed  on 
the  day  of  its  birth,  was  found  to  exceed  twelve  pounds.  Here  was 
an  extraordinary  development  of  size  at  full  term,  and  a  similar  excess 
of  growth  was  undoubtedly  the  case  with  the  previously  aborted  fetus. 

The  seventh  month  is  generally  viewed  as  the  shortest  period  in 
which  a  viable  child  may  be  born,  yet  there  are  many  instances  in 
which  it  has  occurred  still  earlier.  These  cases,  do  not  however 
militate  against  the  general  view  regarding  viability,  and  should  be 
considered  exceptional,  exerting  no  influence  as  to  the  justifiability  of 
inducing  premature  labor  at  the  seventh  month,  in  the  hope  of  pre- 
serving the  life  of  the  child.  Dr.  Dewees  states,  that  he  has  known 
instances  of  this  kind :  one  "  in  which  labor  habitually  occurred  at  the 
seventh  month,  and  two,  in  which  it  regularly  took  place  at  the  eighth 
month  of  pregnancy."  In  Scotland,  a  child  born  six  months  after 
marriage,  or  after  the  death  of  the  father,  is  considered  legitimate. 
Carpenter,  in  his  Physiology,  mentions  an  instance  in  which  a  child, 
born  twenty-five  weeks  after  wedlock,  lived  between  six  and  seven 


OF    PEEGNANCY.  177 

months,  and  was  declared  to  be  legitimate  by  the  Presbytery  of  Scot- 
land. Dr.  Dodd  and  Dr.  Christian  relate  similar  cases,  as  well  as 
many  other  physicians.  Dr.  "W.  Hunter  observes,  that  "  a  child  may 
be  born  alive,  at  any  time  after  three  months ;  but  we  see  none  with 
powers  of  living  to  manhood,  or  of  being  reared,  before  seven  calen- 
der months,  or  near  that  time.  At  six  months  it  can  not  be."  Beside 
the  many  recorded  cases  where  children,  born  previous  to  the  seventh 
month,  lived  for  an  hour  to  several  days  or  weeks  thereafter,  it  may  be 
interesting  to  refer  to  the  following :  M.  Capuron  mentions  the  case 
of  Fortunio  Liceti,  who,  born  after  a  gestation  of  four  months  and  a 
half,  lived  subsequently  for  eighty  years.  M.  Devergie  relates  the  case 
of  Cardinal  Richelieu,  who  was  born  at  the  fifth  month.  Dr.  Hamilton 
cites  a  case  where  a  child  born  only  nineteen  weeks  after  conception 
lived  eighteen  months.  Dr.  Lavirotte,  in  Lyon  Me'dical,  April,  1873, 
observes  that  viability  does  not  solely  depend  upon  the  intra-uterine 
age  of  a  fetus,  but  likewise  upon  its  volume,  its  weight,  its  muscular 
force,  the  more  or  less  advanced  organization  of  its  skin  and  nails,  and 
especially  upon  respiration,  digestion,  nutrition,  and  normal  condition 
of  the  heart  and  large  blood-vessels.  The  fact  that  a  child,  born  at 
the  seventh  month  of  gestation,  may  subsequently  continue  to  live,  is 
of  importance  in  another  point,  viz.:  the  induction  of  premature  labor. 
Upon  these  various  deviations  from  the  most  common  course  of 
pregnancy,  it  is  not  my  intention  to  offer  any  speculative  views,  as  the 
present  work  is  intended  to  be,  not  one  of  theorizing,  but  of  utility  in 
a  practical  point,  to  those  who  consult  its  pages ;  I  will,  therefore, 
leave  this  subject,  by  observing,  that  an  opinion  in  these  cases  should 
always  be  given  very  guardedly  and  reservedly,  lest  by  a  hasty  and 
improper  decision  we  tarnish  the  reputation,  and  consequent  happiness 
of  the  innocent. 

It  sometimes  happens  that  the  ovum,  after  impregnation  does  not 
reach  the  cavity  of  the  uterus,  but  becomes  attached  to  the  interior 
walls  of  the  Fallopian  tubes,  abdomen,  etc.,  in  consequence  of  which, 
from  want  of  a  proper  and  natural  connection  with  the  mother,  the 
development  of  the  ovum  is  much  retarded,  is  seldom  perfected  and 
disease  often  attacks  it;  under  these  circumstances,  a  well-formed 
living  fetus  could  not  be  produced.  I  am  aware,  that  some  writers  ob- 
ject to  these  facts  as  being  without  foundation ;  but  the  objections  are 
commonly  presented  by  those  who  support  the  theory  that  the  male 
semen  never  extends  beyond  the  uterine  cavity,  within  which,  alone*, 

fecundation  occurs.     As  before  stated,  the  spermatic  fluid   has   been 
12 


178  KINc's     FCLKCTIC    Ol'.STKTRICS. 

found  in  the  tubes,  and  on  the  ovaries  of  various  animals  by  rigid  in- 
vestigators; beside,  the  fact  that  fetal  formations,  without  the  uterus, 
do  occasionally  exist,  is,  in  connection  with  the  above,  an  evidence 
tending,  to  say  the  least  of  it,  to  support  a  belief  of  the  possibility,  as 
well  as  the  probability,  of  fecundation  occurring  beyond  the  uterine 
cavity. 

When  the  impregnated  ovum  reaches  the  uterus,  and  is  developed 
within  its  cavity,  it  is  termed  a  normal  or  uterine  pregnancy,  which  is 
divided  into  simple  uterine  pregnancy,  when  there  is  but  one  fetus ;  com- 
pound or  multiple  pregnancy,  when  there  are  more  than  one ;  and  mixed, 
complex,  or  complicated  pregnancy,  when,  with  the  existence  of  the 
fetus,  there  is  also,  a  mole,  hydatids,  or  some  morbid  condition  of  the 
uterus,  or  its  appendages.  When,  instead  of  passing  into  the  uterus, 
the  vivified  ovulum  becomes  fixed  upon  the  tubes,  abdomen,  etc.,  it  is 
called  extra-uterine  pregnancy,  of  which  there  are  several  varieties,  ac- 
cording to  the  place  of  adhesion  of  the  ovum,  and  which  I  wilt  refer 
to  in  the  ensuing  chapter.  To  those  pathological  conditions  which 
simulate  pregnancy,  often  misleading  both  the  patient  and  her  physi- 
cians, and  which  occur  independently  of  true  conception,  the  term 
false  pregnancy  has  been  improperly  applied. 


CHAPTEK    XIX. 

COMPOUND    AND    MIXED    PREGNANCY. 

COMPOUND  or  multiple  pregnancy,  are  the  terms  applied  to  those 
pregnancies  in  which  more  than  one  fetus  exists  within  the  uterus  at 
the  same  time.  The  cause  of  this  peculiar  disposition  which  some 
•women  have  to  compound  pregnancies,  is  a  matter  of  mere  conjecture, 
and  but  little  is  known  relative  to  it  which  is  either  satisfactory  or 
worthy  of  confidence.  It  has  been  attributed  to  the  impregnation  of 
two  or  more  Graafian  vesicles  during  a  fruitful  embrace,  and  which  may 
happen  either  in  one  or  both  ovaries;  again,  and  with  some  degree  of 
probability,  it  is  stated  that  one  vesicle  may  contain  two  or  more  ovules, 
each  of  which  becomes  fecundated  upon  the  rupture  of  the  vesicle 
during  copulation.  By  some  physiologists  it  has  been  supposed  that 
this  anomaly  is  not  the  result  of  one  act  of  impregnation  but  of  two 
or  more,  and  this  is  undoubtedly  true  in  many  instances,  as  examples 


COMPOUND  AND  MIXED  PREGNANCY.  179 

are  011  record  of  females  having  given  birth  to  twins,  one  being  white 
and  the  other  colored,  the  result  of  intercourse  successively  with  a 
white  man  and  a  negro.  And  previous  to  the  secretion  of  the  mucus 
which  fills  the  canal  of  the  cervix  during  gestation,  or  to  the  appear- 
ance of  the  membrana  decidua,  superfetation  may  be  possible. 

Cases  of  a  marvelous  and  probably  fabulous  character,  are  recorded 
where  women  have  given  birth  to  five,  six,  or  even  nine  children  at 
one  birth,  but  it  is  rarely  the  case  that  more  than  two  are  present 
during  pregnancy.  In  the  course  of  a  practice  of  thirty-one  years,  I 
have  met  with  but  three  cases  of  triplets,  and  one  in  which  a  woman 
had  four  children  at  one  birth,  all  closely  resembling  each  other; 
while  of  twins  or  couplets  I  have  met  with  quite  a  number,  averaging 
•about  one  in  every  eighty  labors.  From  the  want  of  sufficient  vital 
force  bestowed  upon  them,  triplets  seldom  attain  adult  age,  and  twins 
rarely  attain  the  meridian  period  of  manhood. 

As  a  general  thing,  in  compound  pregnancies,  each  fetus  or  embryo 
•is  surrounded  by  its  own  proper  membranes,  the  chorion  and  amnion, 
so  that  the  children  do  not  come  in  contact  with  each  other ;  but  have 
between  them  four  layers  or  laminse,  the  two  amnios,  and  the  two 
chorions  which  touch  each  other.  Sometimes}  one  chorion  incloses 
both  ovules,  each,  however,  being  enveloped  with  its  proper  amnion, 
and  in  which  case  there  are  but  two  layers  or  laminse  separating  them, 
the  two  amnios  which  rest  against  each  other.  Occasionally,  the 
fetuses  are  all  inclosed  in  one  amniotic  cavity;  and  very  rarely,  one 
fetus  is  contained  within  the  body  of  another. 

In  the  first-mentioned  variety,  should  the  placentas  be  united,  there 
will  be  no  vascular  communication  between  them;  and  should  one 
child  die  while  within  the  uterus,  it  will  not  necessarily  involve  the 
life  of  the  other;  this  will  frequently  be  found  to  occur  in  twin  and 
triple  pregnancies.  The  same  labor  may  expel  both  children,  or,  if 
permitted,  one  child  may  be  born  two  or  three  days  earlier  than  its 
brother. 

In  the  second  variety,  the  chorion  being  common  to  each,  there  will 
be  two  cords  and  but  one  placenta,  and  as  in  the  first,  one  fetus  may 
continue  to  live  independent  of  the  death  of  the  other.  In  this  variety 
the  birth  of  the  two  children  must  take  place  during  one  labor,  the 
one  being  immediately  expelled  after  the  other. 

In  the  third  variety,  one  placenta  will  be  common  to  each,  with  two 
cords,  which  sometimes  extend  to  the  placenta,  and  at  others  bifurcate 
from  one  common  trunk  at  various  distances  from  the  placenta.  In 
these  cases,  we  often  meet  with  monstrosities  or  imperfectly-formed 


180  KING'S   i-:< •].}•-.( TIC  OHSTKTRICS. 

children.  The  birth  of  the  children  must  take  place  in  this  as  in  the 
second  variety,  during  one  labor;  and  possibly,  the  death  of  one  may 
endanger  the  life  of  the  other. 

In  the  last  form,  monstrosity  is  frequently  the  result.  One  fetus 
may  be  inclosed  in  the  abdominal  cavity  of  the  other,  which  is  termed 
profound  or  abdominal  inclusion;  or,  it  may  be  merely  surrounded  by 
the  integuments  of  the  other,  forming  an  external  tumor  having  no 
communication  with  its  internal  cavities,  which  is  termed  the  cutaneous 
or  exterior  inclusion. 

There  are  no  positive  signs  by  which  we  can  indicate  the  existence 
of  twin  pregnancy,  although  some  have  been  noticed  by  writers. 
Thus,  an  unusual  development  of  the  uterus — but  this  may  be  owing 
to  an  increase  of  the  liquor  amnii ;  a  flattening  or  longitudinal  depres- 
sion of  the  abdomen  on  the  median  line,  in  connection  with  the  above, 
might  justly  give  rise  to  a  suspicion  of  twins,  but  this  could  only 
happen  when  the  fetuses  lie  one  upon  each  side  of  the  uterus;  two  dis- 
tinct shocks  or  motions,  are  sometimes  felt  at  the  same  time  in  different 
parts  of  the  uterus,  but  no  reliance  can  be  placed  upon  this  as  a  sign ; 
again,  ballottement  is  exceedingly  difficult  in  compound  pregnancies, 
as  one  child  must  necessarily  interfere  with  the  ascent  of  the  other. 
Auscultation  has  been  named  as  a  mode  of  detecting  twin  pregnancies, 
but  we  may  err  even  in  this,  as  the  sound  of  the  fetal  heart  can  often 
be  distinctly  heard  in  distant  parts ;  Cazeaux  says,  "  Whenever  the  pul- 
sations are  heard  at  two  distant  points,  the  line  between  these  should 
be  carefully  sounded  with  the  instrument ;  for  if  they  are  produced 
'by  the  presence  of  two  fetuses,  the  pulsations  will  become  feeble,  or 
almost  disappear  toward  the  center  of  this  line;  but  if,  on  the  con- 
trary, they  are  due  to  a  single  child,  they  will  be  just  as  strong  at  its 
middle  part  as  at  either  extremity."  The  diagnosis  is  rendered  more 
certain  if  with  these  varied  pulsations  we  ascertain  them  to  be  non- 
synchronous  in  action,  and  with  a  different  rhythm.  However,  it  is 
of  little  importance  to  determine  the  presence  of  more  than  one  fetus 
within  the  uterus  during  gestation,  as  a  knowledge  of  it  could  be  of 
no  utility  whatever,  until  parturition  had  taken  place,  at  which  time 
it  can  readily  be  detected. 

Compound  pregnancy,  in  consequence  of  the  excessive  development 
of  the  uterus,  frequently  induces  labor  previous  to  full  term,  and  it  is 
not  uncommon  in  these  instances  to  find  the  uterus  contracting  and 
expelling  its  contents  during  the  seventh  and  eighth  months  of  utero- 
gestation. 


COMPOUND   AND   MIXED   PREGNANCY.  181 

In  addition  to  the  above  there  are,  1st,  false  pregnancies,  improperly 
«o  called,  in  which  the  uterus  contains  a  false  germ,  mole,  or  hydatidi- 
form  o-rowths;  and  2d,  mixed  pregnancies,  where  the  uterus  contains 
both  a  fetus  and  mole. 

Moles  and  hydatoid  iormations,  are  undoubtedly  the  results  of 
some  diseased  condition  of  the  ovum,  by  which  it  becomes  destroyed, 
or  metamorphosed,  into  a  growth  possessing  sufficient  vitality  to  exist 
and  augment  in  size,  until  removed  by  the  uterine  contractions.  It  is 
a  true  conception  at  first,  but  which  becomes  blighted  by  disease,  and 
degenerates  into  morbid  development.  The  vesicular  mole  is  more 
generally  met  with,  though  it  is  rare  to  find  it  perfect,  and  in  the  ex- 
amination of  abortive  ova,  vesicular  degeneration  of  the  chorionic 
tufts  will  very  often  be  found,  and  in  the  membranes  of  fetuses  born 
at  the  full  time  a  few  stalked  vesicles  may  be  seen.  (Fricker.}  Other 
moles  may  form  from  a  hypertrophied  condition  of  the  membranes, 
from  hemorrhage  between  the  decidual  layers,  or  into  the  placental  cells, 
etc.,  and  consist  of  a  mass  of  solid  substance.  The  disease  occasioning 
the  vesicular  form  may  commence  with  the  ovum  in  the  ovary;  if  the 
solid  mole  be  the  result  of  an  abnormal  condition  of  the  nidal  decidua, 
it  may  possibly  occur  without  impregnation,  or  even  copulation,  but 
such  cases  are  extremely  rare. 

These  false  pregnancies  are  extremely  difficult  to  detect.  When  the 
uterus  increases  in  size  with  greater  rapidity  than  is  natural  under 
ordinary  causes,  with  nausea,  or  vomiting,  and  tendency  to  fainting, 
more  severe  than  with  normal  pregnancy,  great  constitutional  irrita- 
bility, occasional  attacks  of  uterine  hemorrhage,  emaciation,  quick 
pulse,  absence  of  the  fetal-heart  sounds,  fetal  movements,  and  ballotte- 
ment ;  a  want  of  correspondence  between  the  duration  of  the  preg- 
nancy and  the  rapid  uterine  development,  occasional  discharges  of 
portions  of  the  mole,  a  presentation  at  the  os  uteri  of  a  substance 
somewhat  like  that  of  the  placenta,  but  between  which  and  the  inner 
margin  of  the  uterine  cavity  the  finger  glides  along  without  difficulty, 
etc.,  we  may  be  led  to  suspect  the  presence  of  hydatidoids ;  and  upon 
a  vaginal  examination,  if  we  find  a  soft  mass  in  the  cervix,  which 
upon  being  roughly  pressed,  bleeds,  and  discharges  upon  the  finger 
portions  of  aqueous  vesicles,  our  suspicion  becomes  certainty.  Under 
these  circumstances  we  must  endeavor  to  promote  an  early  expulsion 
of  them.  The  index  finger  may  be  passed  within  the  os  uteri  suffi- 
ciently far  to  reach  the  mass  and  break  it  in  pieces;  as  soon  as  the 
contractions  of  the  uterus  have  removed  the  detached  pieces,  we  must 
examine  again  to  ascertain  whether  any  portion  remains,  and  if  any 


182  KING'S   KCLECTIC  OIISTKTUICS. 

are  found,  they  must  be  again  broken,  and  thus  proceed  till  the  whole 
mass  is  discharged.  If  the  finger  can  not  be  readily  introduced  for  the 
above  purpose,  a  sponge-tent  may  be  placed  in  the  canal  of  the  cervix 
for  the  purpose  of  inducing  uterine  contractions,  or  ergot  may  be 
administered.  Dr.  Lawson  Tait's  compressed  carbolized  sponge-tent 
may  also  be  used,  or  Molesworth'a  uterine  dilator. 

The  prognosis  is  not  very  favorable  in  molar  pregnancy,  as  the 
woman  is  exposed  to  death  from  hemorrhage,  from  the  effects  of  the 
operative  assistance  more  generally  required,  and  from  remote  acci- 
dents; and,  even  should  recovery  ensue,  she  may  suffer  for  a  long 
time  from  extreme  debility,  anemia,  etc. 

Hemorrhage  to  an  alarming  extent  often  accompanies  a  labor  for 
the  expulsion  of  hydatidiform  growths,  for  which,  in  the  early  months, 
the  tampon  may  be  employed,  or  the  os  uteri  and  vagina  may  be 
plugged  by  means  of  muslin  torn  into  strips,  or  a  sponge  saturated  in 
a  mild  solution  of  per-sulphate  of  iron;  together  with  other  means  for 
arresting  uterine  hemorrhage  referred  to  under  the  head  of  Abortion, 
while  at  the  same  time  the  strength  and  general  condition  of  the  pa- 
tient must  be  closely  attended  to.  In  cases  where  the  practitioner  is 
thoroughly  satisfied  that  the  uterus  does  not  contain  a  living  fetus, 
the  previous  symptoms  of  pregnancy  having  disappeared,  and  there 
is  a  continued  hemorrhage  gradually  reducing  the  patient,  the  safest 
plan  is  to  dilate  the  cervix,  examine  the  uterine  cavity,  and  at  once 
remove  any  form  of  molar  pregnancy  contained  therein,  or  any  dead 
fetus;  or,  if  it  be  a  tumor  that  has  occasioned  the  uterine  develop- 
ment, treat  it  according  to  the  indications. 

Mixed  pregnancies  are  likewise  very  difficult  to  distinguish,  and  are 
almost  always  a  cause  of  abortion,  at  which  time  the  practitioner  must 
be  watchful  of  the  hemorrhage  which  may  ensue,  endeavoring  to  check 
it,  if  possible,  that  the  fetus  may  be  saved ;  but,  in  any  case,  when  the 
hemorrhage  is  profuse,  and  does  not  readily  yield  to  treatment,  the  safest 
method  will  be  to  cause  a  speedy  discharge  of  the  uterine  contents. 

When  the  ovule  becomes  impregnated  within  the  ovary,  it  is  seized 
upon  by  the  fimbriated  extremity  of  the  Fallopian  tube,  through  the 
canal  of  which  it  passes  until  it  enters  the  cavity  of  the  uterus,  in 
which  it  becomes  gradually  and  fully  developed.  Many  writers  be- 
lieve that  fecundation  takes  place  only  within  the  uterus,  but  the  exist- 
ence of  extra-uterine  pregnancies  proves  that  it  may  ensue  in  the  ovary 
itself;  and  the  idea  advanced  by  some  that  the  ovule  after  impregna- 
tion may  make  a  retrograde  movement  from  the  uterine  cavity  through- 


COMPOUND    AND    MIXED    PREGNANCY.  183 

the  tubes  to  the  ovary  or  abdomen,  is  both  absurd  and  opposed  to 
reason.  Undoubtedly  impregnation  may  take  place  in  the  ovary, 
tubes,  or  within  the  uterus,-  whenever  the  male  semen  comes  in  contact 
with  the  matured  ovum  at  any  of  its  various  points  of  discharge. 
However,  let  it  occur  where  it  may,  it  is  occasionally  found  that  the 
ovum  does  not  reach  the  uterine  cavity,  but  is  arrested  or  diverted 
from  its  route,  and  attaches  itself  upon  some  unnatural  point,  from 
which  it  proceeds  toward  a  partial  development;  these  instances  are 
termed  abnormal,  or  extra-uterine  pregnancies. 

The  causes  of  extra-uterine  pregnancy  are  involved  in  much  obscu- 
rity ;  in  some  instances  there  have  been  found  partial  or  complete  ob- 
literation of  the  canal  of  the  tubes,  either  at  some  particular  point,  or 
throughout  their  whole  extent,  but  the  occasion  of  these  closures  or 
their  period  of  occurrence,  is  not  satisfactorily  explained.  Blows  upon 
the  hypogastrium  soon  after  conception,  have  been  named  among  the 
causes,  though  there  is  no  certainty  in  relation  to  the  subject,  which  is 
still  one  of  inquiry.  Cases  are  recorded  in  which  fecundation  took 
place,  although  the  tubal  canals  were  imperforate  throughout,  and 
many  others  where  it  has  occurred,  without  a  rupture  of  the  hymen, 
eo  that  notwithstanding  what  has  been  advanced  in  relation  to  the  mat- 
ter of  impregnation,  much  yet  remains  for  investigation. 

In  the  early  period  of  extra-uterine  pregnancy,  its  determination  is 
very  difficult,  if  not  impossible.  At  a  later  period,  we  may  be  led  to 
suspect  the  presence  of  extra-uterine  pregnancy,  when  we  discover  a 
premature  enlargement  of  the  abdomen  above  the  symphysis  pubis — 
when  this  enlargement  is  less  uniformly  developed,  and  more  irregular 
in  its  shape,  than  in  normal  pregnancies — when  the  tumor  or  enlarge- 
ment is  foilnd.  in  one  of  the  iliac  fossae,  or  not  central  in  the  median 
line,  being  easily  felt  through  the  parietes  of  the  abdomen — and  when 
upon  a  vaginal  examination,  the  uterus  is  found  not  to  have  increased 
in  size,  nor  undergone  any  change  from  a  firm,  unyielding  tissue,  to 
one  softened  and  elastic ;  and  very  often  this  organ  will  be  found 
pressed  by  the  abnormal  tumor  against  some  part  of  the  pelvic  walls. 
The  cervix  is  apt  to  be  patulous.  Pain  is  generally  present,  especially 
when  the  motions  of  the  fetus  can  be  felt,  and  which  gradually  be- 
comes more  severe  as  its  development  proceeds.  The  pain  is  some- 
what similar  to  uterine  pains,  and  at  times  it  is  constant,  fixed,  and  cir- 
cumscribed in  the  pelvis,  groin,  or  umbilical  region.  We  may  be 
positive  of  extra-uterine  pregnancy  when,  having  ascertained  fetal 
movements,  fetal-heart  pulsations,  etc.,  the  sound  detects  an  empty 
state  of  the  uterine  cavity.  While  it  exists,  some  of  the  symptoms  of 


184  KINC'S     K(  •!.!•:< 'TIC    <>l!STKTi;irS. 

pregnancy,  as  cessation  of  menstruation,  nausea,  vomiting,  mammary 
enlargement,  etc.,  may  be  present ;  but  in  many  instances  these  have 
been  absent.  There  is  a  discordance  of  opinions  among  writers  rela- 
tive to  the  membrana  decidua,  some  of  whom  assert  that  the  internal 
surface  of  the  uterine  cavity  becomes  covered  with  it  during  extra- 
uterine  pregnancy,  while  others  deny  it;  among  the  latter  may  be 
named  Dr.  Robert  Lee,  of  London.  But  the  statements  of  M.  Caz- 
eaux,  Prof.  Meigs,  Ramsbotham,  and  other  investigators,  tend  to  prove 
conclusively,  that  the  membrana  decidua  is  formed  within  the  uterine 
cavity  in  abnormal  pregnancies.  Ramsbotham  remarks,  "  It  is  a  cu- 
rious circumstance  in  the  history  of  these  cases,  that  if  the  child  should 
live  until  the  term  of  gestation  is  completed,  as  soon  as  that  time  has 
expired,  the  uterus  takes  on  itself  expulsive  action,  which  is  attended 
with  pain  similar  to  the  throes  of  labor,  and  during  these  pains  the 
deciduous  membrane  is  expelled  from  the  cavity,  with  a  slight  san- 
guineous discharge ;  the  same  also  occurs  on  the  death  of  the  ovum, 
provided  that  be  premature."  See  Nidation*  In  these  pregnancies 
we  will  frequently  discover  an  increase  of  the  uterine  volume,  with 
ramollissement,  especially  during  the  early  stages,  and  will  sometimes 
find  a  thick,  ropy,  gelatinous  substance  or  mucus  in  the  uterine  neck. 
Great  care  is  necessary  not  to  confound  extra-uterine  pregnancy  with 
displacement  of  the  normally  pregnant  uterus  during  the  early  months, 
pregnancy  complicated  with  fibro-myoma  or  cystic  disease  of  the 
uterus,  and,  after  the  death  of  the  fetus  especially,  with  pelvic  hema- 
tocele,  ovarian  tumor,  dermoid  cysts,  cancer,  fibro-cystic  uterine  dis- 
ease, uterine  hydatiform  growths,  and  phantom  pregnancy. 

The  duration  of  extra -uterine  pregnancy  is  very  variable;  most 
commonly  it  terminates  in  a  few  weeks  or  months  ;  seldom  exceeding 
five  months;  and  occasionally  it  has  continued  through  a  series  of 
years,  even  as  long  as  forty-six  years.  It  is  stated,  that  in  those  cases, 
where  it  has  continued  during  the  full  period  of  labor,  there  have  been 
at  the  termination  of  the  ninth  month,  symptoms  simulating  labor,  as 
intermittent  uterine  pains  more  or  less  severe  in  character,  a  com- 
mencement of  dilatation  of  the  os  uteri,  a  discharge  of  muco-sanguine- 
ous  fluid,  and  true  uterine  contractions ;  and  where  this  condition  has 
continued  for  several  years,  these"  phenomena  have  recurred  at  fixed  or 
irregular  periods — but  they  are  by  no  means  constant. 

The  most  common  termination  of  extra-uterine  pregnancy,  is  by  a 
rupture  of  the  cyst  which  incloses  the  fetus,  and  which  may  be  effected 
by  a  blow,  violent  exertion,  or  some  similar  cause,  or  it  may  ensue 
slowly  and  gradually.  This  rupture  is  accompanied  with  several 


COMPOUND  AND  MIXED  PREGNANCY.  185 

symptoms  of  a  grave  nature;  at  first,  there  will  be  severe  pain  for 
several  hours,  and  finally  an  agonizing  pain  will  be  followed  by  tran- 
quillity and  a  perfect  quiet  from  suffering,  with  a  subsidence  or  flatten- 
ing of  the  abdominal  enlargement,  or,  perhaps,  its  entire  disappear- 
ance ;  the  abdominal  cavity  experiences  an  increased  heat,  and  the 
patient,  if  the  development  was  of  some  months'  date,  will  feel  as  if  a 
voluminous  body  had  been  displaced ;  the  skin  grows  pale,  faintings 
come  on,  the  pulse  becomes  small  and  contracted,  a  cold  sweat  covers 
the  whole  body,  and  frequently  death  follows,  owing  to  the  hemor- 
rhage produced  by  the  rupture  of  the  cyst.  Or,  if  hemorrhage  to  a 
copious  extent  should  not  ensue,  or  it  should  be  arrested,  violent 
peritoneal  inflammation  will  be  the  result.  The  fetus  in  all  these 
cases  is  usually  dead,  which  may  have  been  the  result  of  defective 
nutrition  or  some  other  cause  unknown ;  and  if  a  new  cyst  is  formed, 
which  is  sometimes  the  case,  although  very  dangerous  to  the  mother,  it 
is  more  favorable,  because  it  may  probably  form  an  abscess  from  which 
the  fetus  may  be  discharged,  and  thus  save  the  patient's  life,  or  it  may 
permanently  hold  the  fetus  while  this  undergoes  several  alterations,  as 
hardening,  or  passing  into  the  state  of  adipocire,  all  the  fluid  parts 
being  absorbed,  and  the  cyst  becoming  gradually  a  solid,  non-malig- 
nant tumor.  Again,  it  may  terminate  in  a  sac  containing  pus,  in 
which  the  fetus  putrefies,  and  is  eventually  discharged  into  the 
peritoneal  cavity,  the  intestine,  or  bladder,  and  which  may  give  rise  to 
violent  peritonitis ;  or,  it  may  become  coated  with  a  bony,  earthy,  or 
semi-coriaceous  crust,  and  remain  comparatively  harmless,  producing 
no  distress,  except  that  occasioned  by  its  weight  and  bulk.  Indeed 
death  is  pretty  certain  in  these  cases,  from  peritonitis,  purulent  infec- 
tion, or  exhaustion  from  long  continued  suppuration. 

Extra-uterine  pregnancies  have  been  divided  into  several  varieties, 
each  variety  being  determined  by  the  point  of  fixation  of  the  ovule, 
thus: 

1.  Ovarian  Pregnancy,  is  that  rare  form  in  which  the  ovum  remains 
adherent  to  the  surface  of  the  ovary,  and  is  of  two  kinds — where  the 
ovule  is  found  within  the  vesicle  which  held  it  previous  to  conception, 
and  where  it  is  partly  developed  in  the  abdomen,  and  partly  in  the 
substance  of  the  ovary  itself.  It  may  continue  for  five  or  six  months, 
when,  from  the  augmented  size  of  the  fetus,  the  cyst  ruptures  during;  a 
paroxysm  of  pain,  and,  as  found  after  death,  the  fetus,  with  a  large 
amount  of  blood  is  expelled  into  the  abdominal  cavity.  During  the 
presence  of  this  abnormal  pregnancy,  most,  excruciating  pain  about 
the  pelvis,  is  experienced  by  the  patient  from  time  to  time,  with  con- 


186  KIN<;'s    K<  LECTIC   OI'.si  I.IK'IOS. 

stipation  and  dysuria ;  and  an  examination  of  the  uterus  per  vaginam, 
detects  it  unaltered  in  size,  form,  and  consistence.  The  pain  is  not 
constant,  but  regularly  or  irregularly  intermittent,  with  intervals  of 
ease.  But  after  the  rupture  of  the  cyst,  the  pain  becomes  more  severe, 
with  syncope  and  finally  death  from  peritoneal  inflammation.  The 
existence  of  this  form  of  extra-uterine  pregnancy,  is  denied  by  some 
authors. 

2.  Tubar,  or  Tubal  Pregnancy,  is  probably  the  most  frequent  variety 
of  extra-uterine  pregnancy.     An  arrest  of  the  ovule  takes  place  in 
some  portion  of  the  Fallopian  tube,  between  its  fimbriated  extremity 
and  its  uterine  orifice,  and  at  which  point  the  imperfect  placenta  be- 
comes attached  to  the  inner  face  of  the  tubal  canal,  the  walls  of  the 
tubes  forming  the  fetal  sac.      The  growth   and  development  of  the 
fetus  proceeds  for  two,  three,  or  four  months,  rarely  seven  or  nine,  when 
the  sac  ruptures.     In  this  form  of  misplaced  pregnancy,  there  is  an 
early  enlargement  over  the  symphysis  pubis,  and  a  vaginal  examination 
will  find  the  uterus  unchanged  in  size,  etc.,  and  movable,  but  uncon- 
nected with  the  mobility  of  the  tumor.     As  the  fetus  continues  to 
grow,  the  female  suffers  severe  pain  in  the  pelvis,  which  is  increased 
after  the  rupture  of  the  sac,  and  is  followed  by  excessive  prostration 
and  death.     The  fetus  is  most  commonly  discharged  into  the  abdom- 
inal cavity. 

3.  In  Ventral,  or  Abdominal  Pregnancy,  the  impregnated  ovule  fails 
to  reach  the  tube  and  falls  into  the  abdomen,  upon  some  portion  of  the 
walls  of  which  the  placenta  attaches  itself.     The  pain,  experienced  by 
the  female  in  this  variety  of  pregnancy,  is  situated  in  the  abdomen; 
the  enlargement  is  found  in  the  iliac  fossa,  at  an  early  period;  upon 
an  examination  per  vaginam,  the  uterus,  as  in  the  previous  species,  is 
found  unaltered,  and  more  movable  than  in  any  other  of  the  abnormal 
pregnancies;  and  the  fetal  movements  may  sometimes  be  observed  till 
the  ninth  month.     The  sac,  which  incloses  the  fetus,  gradually  forms 
adhesions  with  the  surrounding  parts,  and  inflammation  most  generally 
occurs,  at  some  period,  followed  by  abscess,  which  discharges  the  fetus, 
in  fragments,  through  the  wralls  of  the  abdomen,  the  vagina,  the  rec- 
tum, or  the  bladder.     Cases  are  reported  in  which  the  fetus  has  re- 
mained within  the  abdomen  for  forty  and  fifty  years,  in  a  mummefied 
or  cretified  condition,  and  others  in  which  normal  pregnancy  occurred 
during  the  presence  of  the  first  fetus  in  the  cavity  of  the  abdomen. 

There  are  several  other  varieties  named  by  authors,  to  which  a  brief 
reference  may  be  made,  as,  Sub-peritoneo-pelvic  pregnancy,  in  which 
the  ovum  is  situated  between  the  two  laminae  of  the  broad  ligament^ 


COMPOUND    AND    MIXED    PREGNANCY.  187 

where  it  becomes  developed,  and  which  is,  probably,  the  least  danger- 
ous of  any,  as  its  situation  favors  the  spontaneous  expulsion  of  the 
fetal  debris,  and  renders  them  more  accessible,  should  their  extraction 
become  necessary ;  Tubo-ovarian  pregnancy,  in  which  the  cyst  sur- 
rounding the  fetus  is  party  formed  by  the  ovary,  and  partly  by  the 
opening  of  the  dilated  tube,  whose  extremities  have  contracted  some 
adhesions  with  the  ovarian  tunic ;  Tubo-abdominal pregnancy,  in  which 
the  cyst  is  partly  made  up  by  the  walls  of  the  tube,  the  placenta  being 
attached  to  their  interior  face,  while  the  other  portion  of  the  surface  of 
the  ovule  is  in  the  cavity  of  the  abdomen,  and  in  which  cavity  the  fetus 
is  usually  developed ;  Interstitial,  or  parietal  pregnancy,  in  which  the 
ovule  penetrates  into  the  midst  of  the  uterine  fibers,  the  cyst  being 
formed  by  these  muscular  fibers  alone — how  this  is  accomplished,  is  at 
present  an  enigma;  Utero-tubal pregnancy,  where  the  ovum  is  retained 
partly  within  the  tubes,  and  partly  within  the  uterine  cavity;  and 
Utero-tubo-abdominal  pregnancy,  in  which  the  fetus  is  in  the  abdominal 
cavity,  the  umbilical  cord  passing  through  the  canal  of  the  tube  and  into 
the  uterus,  to  the  inner  face  of  which  organ  the  placenta  is  attached. 

In  all  these  abnormal  pregnancies;  ihe  ovule  retains  its  proper 
membranes,  as  the  chorion  and  amnion,  by  means  of  the  first  of  which 
circulation  is  effected  *bet\veen  the  mother  and  embryo,  and  in  those 
cases  where  inflammation  has  been  produced  by  the  presence  of  the 
ovum  in  the  peritoneal  cavity,  a  membraneous  cyst  is  formed  somewhat 
similar  to  the  caducous  membrane  of  the  uterus,  but  undoubtedly  not 
a  true  decidua. 

TREATMENT. — Diagnosis  of  extra-uterine  pregnancy  is  always 
difficult.  Menstruation  is  apt  to  recur  in  a  few  months ;  the  peculiar 
sensations  of  pregnancy  usually  experienced  by  the  patient  are  not 
always  present,  and  a  physician  is  seldom  called  until  an  advanced 
period,  and  often  only  at  the  time  when  rupture  of  the  cyst  is  about 
to  ensue.  It  is  best  determined  by  palpation  of  the  abdomen,  and 
careful  vaginal  exploration ;  and  may  be  decided  by  exclusion,  after 
bimanual  and  pelvic  examination,  that  the  abdominal  enlargement  is 
neither  salpingian  nor  ovarian ;  that  it  is  not  the  result  of  hypertrophy 
of  the  abdominal  or  pelvic  viscera,  but  must  depend,  after  excluding 
every  kind  of  swelling  except  that  of  abdominal  pregnancy,  on  ectopic 
gestation.  The  best  treatment  at  this  critical  period  is  to  execute  lap- 
arotomy  and  remove  the  fetus  with  its  surroundings,  as  soon  as  dis- 
covered, whether  the  ovum  be  dead  or  alive.  Morphine,  injected 


188  KING'S  ECLECTIC  OBSTETRICS. 

hypodermically  into  the  fetal  cyst,  has  been  recommended  to  produce 
the  death  of  the  fetus.  It  has  also  been  advocated  that  electricity  be 
employed  for  the  same  purpose ;  the  object  being  to  prevent  the  growth 
of  the  ovum  and  ultimate  bursting  of  the  sac.  If  the  dead  i^tuo  re- 
main incarcerated  in  the  abdominal  sac,  the  woman  will  sooner  or  later 
develop  septicaemia — the  result  of  putrefactive  gases  arising  from  the 
decomposing  fetus.  Infection  always  follows  the  death  of  the  fetus, 
though  the  poisoning  in  some  cases  is  so  slow  that  it  has  taken  years 
to  wear  out  the  victim.  A  process  of  ulceration  may  establish  a  fistu- 
lous  outlet,  through  which  will  pass  the  fetal  bones  denuded  of  flesh; 
as  the  decomposing  mass  is  cast  off,  inflammatory  action  develops,  ad- 
hesions exist  between  the  pelvic  viscera,  intestines  and  sac,  rendering 
separation  impossible,  and  the  death  of  the  mother  soon  follows  as  the 
inevitable  result. 

In  the  execution  of  laparotomy,  to  remove  the  product  of  extra- 
uterine  conception,  the  same  general  rules  should  be  observed  as  in 
ordinary  ovariotomy.  The  following  instructions  are  given  by  one  of 
the  best  known  writers  on  surgical  subjects :  The  patient  is  to  be  in 
a  clean  and  comfortable  room,  on  a  table,  and  with  clothing  fresh ;  the 
abdomen  is  to  be  sponged,  and  it  is  well  to  have  a  rubber  cloth  cover 
the  skin,  an  aperture  having  been  cut  in  the  cover  in  the  median  line 
to  operate  through ;  pans  of  hot  water  or  antiseptic  fluids  are  to  be  at 
hand,  and  scrupulously  clean  sponges;  all  instruments  are  to  be  un- 
questionably aseptic,  as  well  as  the  operator's  hands  and  arms;  the 
patient  is  to  be  kept  steadily  under  the  anesthetic,  and  it  is  well  to 
have  the  limbs  tied  to  the  operating  table,  to  prevent  troublesome 
movements  of  the  body.  The  abdominal  incision  is  to  be  along  the 
linea  alba,  just  below  the  umbilicus,  and  extended  enough  to  admit 
the  hand ;  after  division  of  the  peritoneal  lining  of  the  abdomen,  a 
quantity  of  serum  may  escape,  and  the  fetal  envelope  come  into  view, 
appearing  redder  and  more  vascular  than  the  sac  of  an  ovarian  cyst. 
This  is  to  be  manipulated  to  determine  the  position  of  the  fetus,,  and 
to  find  its  connections  with  the  Fallopian  tube  or  with  the  peritoneal 
surface  of  the  uterus.  Generally,  the  pedicle  of  the  ovum  is  as  small 
as  that  of  ovarian  tumors  in  general,  but  it  may  be  larger  or  more 
extensive  in  its  attachments.  But,  be  the  pedicle  large  or  small,  it 
must  be  ligated  and  then  severed  with  scissors  on  the  distal  side  of  the 
knot.  After  the  ligature  is  tied,  the  sac  may  be  opened  and  the  fetus 
removed ;  then  the  pedicle  may  be  divided  a  half  inch  or  more  out- 
side the  line  of  strangulation.  Adhesions  are  to  be  overcome  before 


COMPOUND  AND  MIXED  PREGNANCY.  189 

or  after  division  of  the  pedicle,  as  the  operator  may  choose,  or  as  may 
be  convenient. 

Scrupulous  care  should  be  exercised  to  arrest  all  bleeding  from  trau- 
matic surfaces,  and  the  long  rubber  drainage  tube  should  be  employed. 
In  other  words,  the  management  of  the  case  is  to  be  like  that  of  hys- 
terectomy or  ovariotomy.  If  the  peritoneal  cavity  could  be  made  dry 
and  free  from  coagula,  there  would  be  no  necessity  for  drainage  tubes, 
but  there  is  no  surety  for  such  an  aseptic  state.  There  will  be  oozing 
after  reaction,  and  a  consequent  fermentation.  The  long  drainage  tube 
does  not  irritate  or  even  create  perceptible  worry,  and  is  very  efficient 
to  carry  off  septic  fluids. 

The  wound  in  the  abdominal  walls  is  to  be  carefully  closed  with  deep 
sutures,  the  outer  end  of  the  drainage  tube  projecting  from  the  lower 
angle  of  the  wound.  Vomiting  on  the  part  of  the  patient  is  to  be 
allayed  by  taking  sups  of  hot  water.  A  hypodermic  injection  of  mor- 
phia is  to  allay  great  pain,  yet  is  not  to  be  employed  unless  there  is 
need  of  an  anodyne.  Nutritious  enernata  may  be  employed  on  the  day 
following  the  laparotomy.  The  drainage  tube  is  to  be  removed  in  the 
course  of  a  week,  or  as  soon  as  offensive  flows  cease.  The  abdominal 
sutures,  which  may  have  been  silver  or  silk,  are  to  be  cut  and  disen- 
gaged as  soon  as  the  tenth,  day,  and  adhesive  strips  put  across  the 
wound  to  aid  the  sutures,  may  be  renewed  as  a  protection  against  ven- 
tral hernia  in  the  line  of  the  incision. 

The  danger  in  the  operation  is  from  peritonitis,  and  that  is  caused 
by  septic  fluids,  which  an  efficient  drainage  tube  carries  away,  espe- 
cially if  irrigation  be  coupled  with  drainage.  Warm  antiseptic  fluids 
are  to  be  forced  into  the  perforated  tube  in  quantities  to  wash  and  rinse 
the  peritoneal  cavity  of  the  abdomen.  Especially  are  the  washing  and 
rinsing  to  be  done  when  there  is  much  febrile  disturbance. 

There  is  a  condition  that  may  be  met  with  in  females  at  almost  any 
period  of  life,  and  whether  they  have  previously  given  birth  to  off- 
spring or  not,  that  has  been  termed  false,  apparent,  or  spurious  preg- 
nancy, and  which  has  sometimes  so  strongly  resembled  pregnancy  as 
to  deceive  very  experienced  practitioners.  There  will  be  found  in 
these  cases,  cessation  of  menstruation,  morning  sickness,  sympathetic 
changes  in  the  mammary  glands,  enlargement  of  the  abdomen,  with 
other  symptoms,  even  to  a  resemblance  of  the  true  pains  of  labor. 
The  patient  is  thoroughly  satisfied  that  she  is  pregnant,  and  frequently 
becomes  indignant  when  this  is  doubted  or  denied;  and  cases  are  re- 
corded in  which  the  females  even  suffered  from  pains  supposed  to  be 


190  KING'S  ECLKCTIC  OBSTETRIC. 

those  of  labor.  And  yet,  when  the  symptoms  present  are  closely  inves- 
tigated, there  will  be  found  some  irregularity  in  their  true  character 
and  proper  development,  together  with  an  absence  of  softening  of  the 
cervix,  of  uterine  enlargement,  of  development  of  the  sebaceous  areolar 
glands  around  the  nipple,  of  fetal  pulsations,  of  ballottement,  etc.  A 
tympanitic  distension  of  the  abdomen,  when  present,  will  give  more 
or  less  resonance  on  percussion.  If  the  patient  be  placed  under  the 
influence  of  chloroform  by  inhalation,  the  semblance  of  pregnancy  will 
promptly  disappear. 

But  little  that  is  satisfactory  is  known  as  to  the  cause  or  pathology 
of  this  condition  ;  hysterical  women,  and  those  who  >uil'er  from  ovarian 
or  menstrual  functional  derangements,  are  more  subject  to  it,  and  a 
tympanic  distention,  in  the  generality  of  cases,  appears  to  be  the  cause 
•of  the  abdominal  enlargement;  but  the  origin  of  this  flatus  is  yc-t  un- 
determined. Sometimes  the  symptoms  will  continue  for  a  longer  time 
than  that  of  normal  gestation,  and  again  they  may  disappear  in  a  few 
weeks  or  months.  In  all  doubtful  cases  of  pregnancy,  a  very  thorough 
and  minute  investigation  should  be  pursued  by  the  practitioner,  espe- 
cially of  the  ovaries,  uterus,  and  abdomen,  and  any  existing  malady  of 
these  organs  be  treated  according  to  the  indications,  while  at  the  same 
time  the  general  health  should  be  attended  to  by  proper  hygienic  and 
other  required  measures. 


CHAPTER    XX. 

SIGNS     OF    PREGNANCY. 

PHYSICIANS  are  frequently  consulted  to  decide  the  existence  or  non- 
existence  of  pregnancy,  in  cases  where  it  may  be  of  immense  impor- 
tance in  determining  the  reputation  of  a  female,  the  legitimacy  of  a 
child,  or  even  the  life  of  a  new  being,  and  in  instances  when  a  preg- 
nant woman  is  condemned  to  capital  punishment.  Hence,  a  knowl- 
edge of  the  signs  common  to  pregnancy  can  not  be  too  thoroughly 
understood  by  the  accoucheur.  Women  with  illicit  offspring,  when 
suspected  and  interrogated,  will  almost  always  endeavor  to  mislead  us 
by  an  obstinate  denial,  and  even  by  an  appearance  of  much  indigna- 
tion ;  and  this  will  usually  apply  to  all  females,  whether  married  or 
not,  who  desire  to  abort,  or  destroy  their  conception.  We  can  not, 
therefore,  be  too  cautious  in  giving  full  credence  to  the  statements  of 
any  female  upon  this  subject,  unless  we  have  a  sufficient  acquaintance 


SIGNS    OF    PREGNANCY.  191 

with  her  to  justify  implicit  confidence  in  her  assertions;  and  we  should 
always  depend  upon  our  own  knowledge  of  the  symptoms,  rather  than 
upon  any  light  we  may  elicit  from  the  female. 

Again,  in  cases  where  there  is  no  desire  or  interest  to  deceive,  as 
when  pregnancy  is  suspected  from  the  presence  of  abdominal  enlarge- 
ment, suppressed  menstruation,  morning  sickness,  etc.,  it  will  often 
require  all  the  skill  of  the  physician  to  diagnosticate  correctly,  and,  if 
an  incorrect  opinion  is  pronounced,  it  will  frequently  place  him  in  an 
extremely  mortifying  situation.  It  is  not  many  years  since,  that  a  cele- 
brated Professor  plunged  the  trocar  into  the  gravid  uterus  and  shoul- 
der of  the  fetus  of  a  woman,  whose  condition  he  mistook  for  dropsy. 
I  know  an  instance  where  a  female,  supposed  to  have  erred,  was  exam- 
ined by  two  or  three  physicians,  who  decided  that  she  was  some  three 
or  four  months  advanced  in  pregnancy;  she  denied  the  charge,  but  if 
was  of  no  avail ;  her  friends  forsook  her,  and  even  her  parents  became 
harsh,  severe,  and  cold  toward  her;  she  pined  away  in  secret,  hiding 
her  grief  from  the  world,  and  in  a  few  months  died.  An  investiga- 
tion being  held,  a  morbid  growth  within  the  uterus  disclosed  the  true 
cause  of  her  symptoms.  Many  instances  of  similar  character  might 
here  be  related,  showing  the  value  and  importance  of  a  full  acquaint- 
ance with  all  the  signs  which  are  to  guide  us  in  our  investigation  and 
decision.  We  should  exercise  great  discretion,  and  rely  entirely  on 
the  indisputable  evidence  of  our  senses;  not  forming  our  opinion  on 
one  sympton,  but  on  a  combination  of  unquestionable  symptoms,  and 
if  the  least  doubt  be  entertained,  we  should  unhesitatingly  express  it; 
for  it  is  much  safer  to  remain  in  uncertainty,  than  to  pronounce  an 
incorrect  diagnosis.  Females  usually  suppose  themselves  pregnant 
when  after  iutercouse  they  find  a  cessation  of  menstruation  followed 
by  an  enlargement  of  the  abdomen  and  fetal  movements  at  a  proper 
time,  and  generally  they  are  correct,  yet  all  these  signs  may  be  appa- 
rently without  conception  present. 

To  determine  a  recent  conception  is  not  only  difficult,  but  as  far  as 
the  physician  is  concerned,  absolutely  impossible;  yet  many  females 
resolve  this  point  very  correctly,  from  certain1  voluptuous  sensations, 
peculiar  to  each,  individually,  experienced  during  a  fruitful  copulation ; 
and  where  they  have  previously  given  birth  to  children,  having  felt 
similar  sensations  at  the  period  of  fecundation,  we  have  on  subsequent 
occasions,  when  these  occur,  some  grounds  for  believing  them  to  be 
again  pregnant.  Yet  it  is  commonly  the  case  that  "cold  women,"  as 
they  are  called,  are  more  easily  impregnated  than  those  warm,  ardent, 


192  KIND'S    ECLECTIC    OBSTETRICS. 

amorous  beings  who,  during  copulation,  enjoy  exquisite  voluptuous 
.-(•fixations,  with  spasms,  and  nervous  agitation. 

The  dryness  of  the  penis  when  withdrawn  after  an  embrace,  and  the 
retention  of  semen  by  the  female,  are  looked  upon  by  some  persons  as 
undoubted  evidence  of 'fecundation.  An  anxiety  or  depressed  condi- 
tion of  the  woman  a  few  days  afterward,  paleness  of  countenance,  a  dull, 
sunken,  languishing  appearance  of  the  eyes,  with  a  bluish  circle  sur- 
rounding them,  spots  on  the  face  of  various  sizes,  and  swelling  of  the 
neck,  have  all  been  enumerated  as  signs  of  early  conception,  but  they 
are  extremely  uncertain  and  doubtful. 

It  is  only  when  pregnancy  has  somewhat  progressed  that  we  are  ena- 
bled to  diagnosticate  with  any  degree  of  confidence,  and  the  more  ad- 
vanced this  is,  the  more  correctly  can  we  decide.  The  signs  of  preg- 
nancy are  divided  into  the  RATIONAL  and  the  SENSIBLE;  the 
rational  are  again  subdivided  into  general,  local,  and  sympathetic, 

The  general  signs  are  those  which  result  from  increased  activity  of 
the  nutritive  functions,  and  from  the  modifications  which  take  place  in 
the  nervous  system.  The  pulse  is  more  frequent  and  strong,  full,  and 
hard;  occasionally,  in  the  latter  months,  intermittent  and  contracted; 
the  blood  is  said  to  be  buify  and  more  plastic;  respiration  is  more  ac- 
tive with  an  augmentation  of  the  heat  of  the  body;  and  all  the  secre- 
tions are  more  abundant,  with  increased  odor.  The  changes  in  the 
nervous  system  are  usually  the  greatest  and  most  remarkable.  The 
sensibilities  become  more  refined,  the  female  becomes  more  susceptible 
as  well  as  more  liable  to  moral  and  physical  influences;  sometimes  her 
nature  appears  completely  changed,  so  that  those  who  were  kind,  lov- 
ing, and  amiable,  become  peevish,  irritable,  jealous,  and  malicious, 
and  vice  versa;  the  silent  become  loquacious,  and  the  talkative  become 
taciturn;  in  some,  the  intellect  becomes  more  active,  and  they  are  ren- 
dered more  subject  to  nervous  derangements.  If  diseases  are  already 
existing  in  the  female  their  further  progress  is  either  retarded  or  more 
rapidly  hastened  toward  a  serious  termination.  Pregnancy  renders 
the  female  system  more  liable  to  disease,  constituting  a  condition  called 
puerperal,  which  is  induced  by  conception — is  more  fully  developed  as 
pregnancy  advances — and  reaches  its  maximum  point  at  childbirth  ;  it 
then  gradually  diminishes  until  after  lactation,  when  it  ceases ;  mani- 
festing itself  again,  in  a  greater  or  less  degree,  during  every  subsequent 
pregnancy.  It  is  owing  to  this  puerperal  condition  that  pregnant  and 
lying-in  women  are  more  liable  to  epidemic  and  other  diseases,  and 
which  are  usually  more  rapid  and  severe  at  this  time  than  during  the 
ordinary  state  and  habits  of  the  animal  economy.  Although  these  signs 


SIGNS    OF    PREGNANCY.  193 

are  indicative  of  pregnancy,  yet  in  the  early  months  they  are  very 
obscure,  and  when  taken  by  themselves  at  any  period,  very  uncertain, 
affording  very  little  aid  in  diagnosis  unless  associated  with  the  others 
hereafter  mentioned. 

Among  the  local  signs,  that  upon  which  females  place  the  greatest 
reliance,  is  the  suppression  of  menstruation ;  this  is,  to  be  sure,  a  valua- 
ble and  most  important  indication,  and  one  that  is  very  common  with 
pregnant  females,  yet  too  much  confidence  must  not  be  placed  in  it  as 
an  unerring  sign.  It  often  happens  that  women  fail  to  menstruate  for 
one,  or  several  periods  in  succession,  without  conception  being  present, 
and  this  may  or  may  not  be  accompanied  with  an  augmented  protuber- 
ance of  the  hypogastric  region.  This  suppression  may  be  owing  to 
cold,  functional  or  organic  disease  of  the  reproductive  system,  or  other 
cause,  which  should  always  be  carefully  investigated  with  a  view  to  a 
correct  solution.  Again,  there  are  many  instances  where  menstruation 
or  a  periodical  sanguineous  discharge  is  present  during  pregnancy — 
others,  where  females  have  conceived  without  any  previous  monthly 
flow,  and,  occasionally,  some  menstruate  regularly,  or  rather  have  a 
periodical  discharge  of  blood,  only  when  pregnant.  Usually,  when 
»the  catamenia  have  failed  in  non-pregnant  females,  there  is  a  greater 
or  less  derangement  in  the  general  health,  but  when  the  health  con- 
tinues in  its  ordinary  condition,  with  a  gradual  enlargement  of  the  ab- 
domen, morning  sickness,  and  the  development  of  the  glandular  fol- 
licles of  the  areola,  we  have  strong  reasons  for  suspecting  pregnancy, 
especially  in  the  married  woman.  In  the  unmarried,  where  illicit 
commerce  is  strenuously  denied,  the  diagnosis  will  be  involved  in  much 
uncertainty  and  difficulty;  yet  the  physician  should  not  bestow  a  too 
ready  credence  on  the  statements  of  his  patient,  but  rather  postpone  a 
positive  declaration,  until  the  other  signs  have  advanced  so  far  as  to 
give  an  undoubted  indication  of  the  true  state  of  the  case.  When  the 
least  doubt  exists  in  the  mind  of  the  practitioner,  he  should  be  very 
particular  not  to  prescribe  or  administer  any  remedies  tending  to  the 
restoration  of  the  monthly  evacuation. 

A  change  in  the  color  of  the  vulva,  from  its  natural  pinkish  hue  to  a 
bluish  tint,  has  been  named  as  a  sign  of  pregnancy ;  but  as  this  is  prob- 
ably owing  to  an  obstructed  circulation,  pelvic  tumors  or  other  abnor- 
mal conditions  may  produce  it.  It  is  usually  more  marked  when  the 
female  is  in  the  erect  or  sitting  posture,  and  disappears  more  or  less 
in  the  recumbent. 
13 


194  KIN(i's    KCL&TIC    OBSTETRK'S. 


A  change  in  the  color  of  the  skin,  called  cpliclix,  and  sometimes  morph, 
or  mask,  accompanies  many  women  during  every  pregnancy.  It  is  a 
brownish,  yellowish,  or  earthy  colored  stain  or  freckle,  of  greater  or 
less  extent,  usually  occupying  the  forehead,  cheeks,  and  even  the  neck 
and  breast,  but  is  not  a  constant  sign  of  pregnancy.  It  is  a  minor  sign2 
and  one,  probably,  more  important  among  those  females  ^Yho  have  been 
disfigured  by  it  in  previous  conceptions.  It  often  becomes  permanent, 
remaining  after  parturition,  and  occasioning  considerable  uneasiness  to 
the  female.  Efforts  have  been  made  to  remove  it  ;  success  has  been 
reported  in  several  instances,  by  employing,  as  a  lotion,  the  saturated 
aqueous  solution  of  Sulphuret  of  Potassa,  to  be  applied  on  the  stain 
three  or  four  times  a  day,  in  connection  with  mild  laxative  agents  to 
regulate  the  bowels  and  restore  the  cutaneo-hepatic  sympathetic  rela- 
tions; but  a  subsequent  conception  has  always  brought  with  it  a  return 
of  the  dark  spot. 

Dr.  Schlesinger,  in  an  address  before  the  Vienna  Medical  Society, 
proposed  to  determine  pregnancy  in  is  earlier  months  by  thermometry. 
From  several  investigations,  he  has  ascertained  that  between  the  axilla 
and  the  vagina  there  is  a  difference  in  temperature  of  0.21°  C.,  and  be- 
tween the  vagina  and  non-pregnant  uterus  of  0.16°  C.;  the  cavity  of  the 
uterus  being  of  a  higher  temperature  than  that  of  the  cervix.  The 
temperature  of  the  fetus  in  utero  is  higher  than  that  of  the  mother, 
and  which  is  imparted  in  a  certain  degree  to  the  uterus.  Hence,  the 
gravid  uterus  is  of  a  still  higher  temperature  than  that  of  the  non- 
gravid.  Pulse  test:  the  pulse  rate  varies  in  health,  from  eight  to  ten 
beats  per  minute,  depending  on  the  upright  or  horizontal  position; 
while  in  pregnancy  it  remains  unchanged  —  is  not  influenced  by  posi- 
tion. This,  it  is  claimed,  is  the  result  of  an  hypertrophied  condition 
of  the  heart,  always  existing  during  pregnancy.  Recent  observers 
claim  this  to  be  one  of  the  most  reliable  among  the  many  signs  of  preg- 
nancy. Further  investigation  should  be  made  and  reported. 

Dr.  A.  Rasch  has  stated  as  among  the  important  early  symptoms 
of  pregnancy,  the  increased  desire  to  void  urine,  especially  at  night,  and 
fluctuation,  which  has  been  detected  as  early  as  the  seventh  week  of 
gestation,  but  generally  after  the  second  mouth.  Two  fingers  are  to 
be  introduced  into  the  vagina,  the  womb  being  steadied  through  the 
abdominal  walls  with  the  other  hand,  and  then  alternately  manipulate 
the  uterus  with  the  two  fingers.  Sometimes  the  fluctuation  will  be 
detected  in  one  corner  of  the  fundus,  sometimes  lower  down  ;  after 
three  months,  outward  manipulation  alone  would  feel  it.  When  the 
fingers  have  diagnosed  an  enlargement,  the  practitioner  must,  of 


SIGNS    OF    PREGNANCY.  190 

course,  determine  whether  it  be  from  hypertrophy,  tumor,  or  preg- 
nancy. When  anteversion  is  present,  as  is  more  generally  the  case 
in  early  pregnancy,  the  above  manipulation  is  more  readily  performed 
than  in  retroversion.  Fluctuation,  combined  with  increased  tempera- 
ture, softening  of  the  cervix,  and  the  areolar  changes  of  the  mamma, 
is  almost  a  certain  symptom. 

The  sympathetic  signs  are  usually  confined  to  the  digestive  system, 
and  are  only  useful  as  means  of  diagnosis  when  taken  in  connection 
with  the  more  positive  sensible  signs;  they  sometimes  become  so 
severe  and  troublesome  as  to  require  treatment,  for  which  the  reader 
is  referred  to  the  chapter  on  "Disorders  of  Pregnancy,  and  Treat- 
ment." Among  the  sympathetic  signs  are  nausea,  or  morning  sick- 
ness, vomiting,  anorexia,  pica,  malacia,  acidity  of  stomach,  heartburn, 
and  toothache,  which  are  more  common  in  the  earlier  months  of  preg- 
nancy, gradually  disappearing  in  the  latter  months,  being  followed  by 
constipation,  hemorrhoids,  and  more  or  less  headache. 

All  the  rational  signs,  of  whatever  subdivision,  are  only  important 
when  accompanied  with  the  sensible  signs,  and  when  they  occur 
together,  the  diagnosis  is  rendered  more  easy  and  certain. 

The  SENSIBLE  SIGNS  are  subdivided  into  the  visible,  the  audi- 
ble, arid  the  tangible. 

The  visible  signs  are  those  which  may  be  recognized  by  the  eye,  as 
enlargement  of  the  mammae.  The  breasts,  during  the  earlier  stages  of 
pregnancy,  acquire  new  life  from  sympathy  with  the  uterus;  the 
lactiferous  glands  are  aroused  into  action,  the  breasts  increase  in 
magnitude,  becoming  round,  tense,  hard  and  tender,  with  frequently 
a  pricking  sensation  in  them,  which  sometimes  continues  during  gesta- 
tion, and  at  other  times  the  enlargement  diminishes  about  the  fourth 
or  fifth  month,  and  may  not  appear  again  until  near  the  period  of 
parturition,  or  even  subsequently.  Occasionally  the  axillary  glands 
enlarge. 

Simultaneously  with  the  augmentation  of  the  breast,  or  about  the 
commencement  of  the  third  month,  the  nipples  increase  in  size  and 
sensitiveness,  and  are  sometimes  quite  painful,  they  become  of  a 
deeper  red,  and  it  is  often  the  case  that  a  yellowish  or  milky  fluid 
can  be  obtained  from  them.  The  surrounding  skin  likewise  becomes 
tense,  thin  and  more  transparent,  and  the  veins  more  conspicuous. 
The  enlargement  of  the  breasts,  and  increased  size  of  the  nipples  are 
most  commonly  present  during  pregnancy,  yet  taken  alone,  they  can 


196  KINCi's    K<  LECTIC    OBSTETRICS. 

not  be  depended  on  as  signs,  for  pregnancy  often  exists  without  them, 
and  again,  they  may  originate  from  other  causes,  as  ovarian  or  uterine 
tumors,  amenorrhea,  etc. 

The  areola,  shortly  after  conception,  becomes  changed  from  its 
natural  pink  color  to  a  deep  brown,  and  which  is  a  more  valuable 
sign  in  first  pregnancies  than  succeeding  ones,  as  in  the  latter  it 
would  be  difficult  to  decide  whether  the  change  was  owing  to  the 
former  pregnancy,  or  the  one  under  examination,  especially,  if  only 
a  short  time  has  elapsed  between  them.  By  some  medical  men, 
especially  Smellie,  'and  Hunter,  it  was  viewed  as  a  positive  sign  of 
pregnancy.  Cazeaux  says,  "and  I  should  diagnosticate  the  existence 
of  pregnancy,  with  a  degree  of  confidence,  in  a  young  woman  who 
had  never  borne  children,  and  whose  breasts  presented  both  a  brown- 
ish-colored areola,  the  tubercles  (sebaceous  glands),  and  the  freckled 
characters  before  described."  But,  notwithstanding,  this  sign  has  its 
objections;  it  is  sometimes  absent  during  pregnancy — it  may  be  modi- 
fied by  the  color  of  the  skin,  being  more  distinct  in  women  with  dark 
hair  and  eyes,  and  less  so  in  blondes  and  brunettes ;  and  it  has  been 
present  when  conception  did  not  exist,  being  induced  by  disease,  as 
amenorrhea,  or  organic  disease  of  the  ovaries,  or  uterus;  all  of  which 
should  be  considered  during  the  investigation. 

With  this  alteration  of  color,  the  papilla?,  or  sebaceous  glands  which 
are  seated  under  the  skin  of  the  areola,  and  especially  near  its  margin, 
become  enlarged,  appearing  like  small  tubercles,  and  which  is  consid- 
ered a  more  positive  sign  of  pregnancy  than  the  areolar  discoloration, 
and  more  especially  so  when  these  enlarged  follicles  contain  sebaceous 
matter. 

The  secretion  of  milk,  is  a  sign  of  some  value ;  yet  the  accoucheur 
must  remember,  that  it  has  occurred  in  females  who  were  not  preg- 
nant, likewise  in  children ;  and  that  cases  are  on  record,  where  milk 
has  been  obtained  from  the  breast  of  the  male.  In  females,  this 
secretion  may  be  present  in  consequence  of  the  sympathy  existing 
between  the  breasts  and  the  reproductive  organs  in  a  state  of  disease  ; 
instances  of  which  are  frequently  met  with ;  consequently,  this  sign  is 
only  of  importance  when  attended  with  others  of  a  positive  character. 
Beside,  it  must  not  be  forgotten  that  disease  may  give  rise  to  the  dis- 
charge of  a  fluid  apparently  resembling  milk,  but  differing  from  it  in 
many  respects. 

Enlargement  of  the  abdomen,  affords  to  the  public  a  strong  presump- 
tion of  pregnancy,  because  it  is  an  invariable  concomitant  of  this  con- 
dition. Yet  a  mere  dependence  on  this  sign  will  often  deceive  us,  as 


SIGNS    OF    PREGNANCY.  197 

it  may  be  present  from  many  other  causes  than  pregnancy.  Thus,  the 
accumulation  of  adipose  matter  in  the  omentum  and  walls  of  the  ab- 
domen, ascites,  uterine  and  ovarian  tumors,  amenorrhea,  tympanitis, 
etc.,  will  cause  its  enlargement.  An  appreciable  increase  of  size,  in 
the  abdomen,  is  commonly  observed  about  the  third  month,  and  if 
with  it  we  have  enlargement  of  the  breasts,  areolar  changes  of  the 
mamrnse,  cessation  of  menstruation,  increased  uterine  temperature, 
fluctuation,  with  usual  health,  and  previous  morning  sickness,  the 
inference  is  strong  that  conception  exists;  yet  even  these  may  mislead 
us;  hence,  the  necessity  for  great  caution  in  forming  a  diagnosis  on 
this  subject,  can  not  be  too  strongly  enforced. 

Previous  to  the  third  month,  or  soon  after  conception,  the  ab- 
domen generally  becomes  flat,  its  anterior  wall  retracts,  and  ap- 
proaches toward  the  vertebral  column ;  but  about  the  third  month,  it 
commences  to  project,  first  on  the  median  line,  gradually  increasing 
and  extending  from  the  pelvic  to  the  umbilical  and  epigastric  regions, 
reaching  this  last  at  full  term,  and  leaving  a  sunken,  or  depressed  ap- 
pearance over  the  iliac  fossa3.  In  women  who  have  had  several  chil- 
dren, the  abdomen  inclines  more  forward  and  downward,  from  laxity 
of  the  parietes,  while  with  those  in  their  first  pregnancies  it  is  usually 
less  projecting,  but  larger  and  more  uniform.  The  volume  of  the 
abdomen,  at  different  stages  of  gestation,  likewise  varies  from  several 
circumstances,  as  twins,  amniotic  dropsy,  etc.  If,  with  the  above 
appearances,  we  ascertain  that  the  umbilicus  is  sunken  at  first,  and 
then  becomes  gradually  more  prominent  as  the  projection  of  the  abdo- 
men proceeds,  our  suspicions  of  pregnancy  are  still  further  corrobo- 
rated. During  the  latter  months  of  pregnancy  the  umbilicus  may  be 
thrust  forward  from  one-fourth  of  an  inch  to  even  an  inch  beyond  the 
anterior  surface  of  the  abdomen ;  and  this  projection  may  also  origi- 
nate from  the  presence  of  pathological  tumors  within  its  cavity. 

Quickening,  a  term  applied  to  a  fluctuation,  or  fluttering  sensation, 
experienced  about  the  end  of  the  fourth  month,  may  be  mentioned  in 
connection  with  the  augmentation  of  the  abdomen.  By  some  authors 
this  is  considered  as  the  result  of  life  being  imparted  to  the  fetus  at 
the  time  it  is  felt ;  by  others,  it  is  viewed  as  being  caused  by  the  im- 
pregnated uterus  when  rising  from  the  pelvic  excavation,  etc.  It  is 
undoubtedly  owing  solely  to  the  fetal  movements,  which  take  place  as 
soon  as  the  embryo  attains  size  and  strength  sufficient  to  make  its 
motions  felt  by  the  mother,  and  which  generally  commences  about  the 
eighteenth  or  twentieth  week  of  utero-gestation.  However,  preg- 
nancy may  exist,  and  no  quickening  have  been  experienced  by  the 


198  KIN<;'S    KCLKCTIC    ( U5STKTR  K  X. 

mother;  again,  females  often  mistake  other  sensations  for  this  symptomr 
as  a  flatulent  motion,  etc.;  yet,  if  the'  sensation  continues  to  increase 
in  strength,  until  the  fetal  movements  can  be  distinctly  felt,  all  doubts 
will  of  course  be  removed.  If,  during  the  latter  months  of  gestation, 
firm  and  continued  pressure  be  made  by  the  fingers  against  opposite 
sides  of  the  uterus,  it  will  produce  such  disturbance  to  the  fetus,  as  to 
make  it  move  vigorously;  or,  if  one  hand  be  placed  on  one  side  of 
the  abdomen,  and  the  same  point  on  the  opposite  side  be  struck  with 
the  other  hand,  the  fetus  is  very  apt  to  move  actively.  The  motion.- 
of  the  child,  if  it  be  alive,  may  likewise  be  determined,  by  dipping 
the  hand  in  a  bowl  of  cold  water,  and  applying  it  suddenly  over  the 
abdomen.  It  must  be  borne  in  mind,  that  although  the  motions  of 
the  fetus  are  a  strong  evidence  of  pregnancy,  yet  its  absence  does  not 
prove  the  reverse  condition,  as  the  child  may  be  dead,  or  very  feeble. 
In  the  strict  sense  of  the  word,  quickening  really  occurs  at  the  period 
of  conception. 

Among  the  visible  signs,  may  be  named  a  peculiarity  observed  in  the 
urine  of  some  pregnant  women,  first  described  by  M.  Nauche,  iii  1831, 
and  after  him  by  several  other  gentlemen.  The  urine  on  being 
allowed  to  stand  in  a  glass  for  some  twenty  or  twenty-four  hours, 
presents  on  its  surface  a  number  of  brilliant,  crystalline  granules, 
resembling  small  specks,  or  oblong  filaments,  irregularly  isolated, 
which  often  unite,  forming  a  transparent  layer  or  pellicle  about  a  line 
in  thickness,  which  can  only  be  seen  in  certain  positions.  After  a  few 
days  a  portion  of  this  pellicle  gradually  falls  to  the  bottom  of  the  glass, 
forming  a  white,  milky  crust  there.  At  one  time  this  pellicle  was 
considered  a  positive  proof  of  pregnancy,  but  the  investigations  of  Dr. 
E.  K.  Kane,  of  Philadelphia,  have  determined,  that  Mesteine,  the 
name  given  to  this  material,  is  not  peculiar  to  pregnancy,  but  may 
occur  during  the  presence  of  milk  in  the  breasts,  especially  if  it  be 
not  freely  discharged  from  the  mammae,  and  that  its  presence  is  rather 
an  indication  of  the  existence  of  this  mammary  secretion,  than  of 
pregnancy. 

• 

The  audible  signs,  are  those  detected  by  the  ear,  with  or  without 
the  aid  of  the  stethoscope,  among  which  is,  the  placenta!  sound,  or 
bruit  de  souffle,  which  is  variously  represented  as  resembling  the  blow- 
ing of  air,  the  cooing  of  a  dove,  the  drone  of  a  bagpipe,  having  a 
peculiar  rasping  sound,  similar  to  that  which  is  heard  in  the  carotid 
arteries  of  chlorotic  females,  in  varicose  aneurisms,  and  in  some  car- 
diac affections ;  this  sound  is  owing  to  the  arterial  and  venous  circula- 


SIGNS    OF    PREGNANCY.  199 

tion  of  the  walls  of  the  impregnated  uterus,  as  well  as  to  pressure 
upon  the  arteries,  and  not  to  the  utero-plaeental  circulation;  it  is 
always  synchronous  with  the  mother's  pulse,  and  is  occasionally  heard 
in  the  course  of  the  linea  alba,  but  more  frequently  on  the  sides  of  the 
abdomen,  over  the  course  of  the  iliac  arteries;  sometimes  it  can  be 
heard  over  a  large  extent  of  surface.  When  the  female  is  placed  in 
such  a  manner  as  to  remove  the  pressure  of  the  gravid  uterus  upon 
the  arteries,  as  upon  her  knees  and  elbows,  this  sound  can  n^ot  be 
heard;  and  there  are  cases  in  which  it  can  .not  be  detected,  although 
the  motions  of  the  fetus  may  be  distinctly  felt.  It  is  first  heard  about 
the  fourth  or  fifth  month  of  pregnancy,  though  some  writers  profess  to 
have  observed  it  even  before  the  end  of  the  third  month,  and  becomes 
more  audible  as  gestation  advances.  This  is  neither  a  constant,  nor  a 
positive  sign  of  pregnancy,  for  it  may  be  owing  to  various  other 
causes,  as  aneurism,  abdominal  tumors,  or  whatever  may  compress  the 
arteries,  and  has  been  heard  even  after  delivery;  hence,  but  little  con- 
fidence is  bestowed  upon  it  at  the  present  day. 

Dr.  Verardini  in  an  address  before  the  Academy  of  Bologna,  stated 
that  intra-vaginal  auscultation  is  of  the  greatest  importance  for  detect- 
ing early  pregnancy,  and  will  enable  us  to  avoid  many  possible  errors. 
The  instrument,  vagina-uteroscope,  may  be  made  of  gutta  percha,  very 
light,  and  of  various  shapes.  By  pressing  the  vaginal  extremity  of 
the  instrument  against  the  cervix  uteri,  if  pregnancy  exist,  a  soft,  pro- 
longed sound  is  heard,  similar  to  that  heard  in  aneurismal  tumors 
when  the  stethoscope  is  pressed  upon  the  arteries,  this  is  the  character- 
istic utero-placental  bruit.  The  examination  may  be  made  writh  the 
patient  lying  upon  her  back  or  side ;  but  if  no  sound  be  heard  in  this 
position,  the  female  should  be  placed  in  the  knee-elbow  position,  when 
the  auscultator  will  succeed  without  difficulty.  The  bruit  which  is 
distinctly  heard  during  the  first  months,  ceases  at  the  commencement 
of  the  sixth  or  seventh  month.  If  the  bruit  be  absent  while  other 
symptoms  common  to  early  pregnancy  are  present,  the  diagnosis  is 
uncertain,  as  there  may  be  uterine  disease.  In  making  the  examina- 
tion, it  is  important  to  be  certain  that  there  is  no  pulsating  tumor  or 
artery  in  the  vicinity  of  the  cervix.  If  the  bruit  continues  to  be 
heard  after  the  seventh  month,  it  is  indicative  of  placenta  prsevia. 

The  sound  of  the  fetal  heart,  differs  entirely  from  the  placenta! 
souffle;  it  closely  resembles  the  ticking  of  a  watch,  and  differs  ma- 
terially from  the  mother's  pulse  in  frequency  and  rapidity,  beating 
from  one  hundred  and  twenty  to  one  hundred  and  forty  in  a  minute, 
the  pulsations  being  sometimes  so  rapid  as  to  render  it  impossible  to 


200  KING'S    ECLECTIC    OBSTETRICS. 

count  them,  but  returning  to  their  natural  character,  without  any 
cognizable  cause. 

The  pulsations  of  the  fetal  heart  are  first  perceptible  between  the 
fourth  and  fifth  months,  and  are  more  commonly  heard  on  the  anterior 
inferior  portion  of  the  abdominal  wall,  just  above  the  iliac  fossa,  oc- 
casionally on  the  median  line,  and  over  an  extent  of  two  or  three 
inches;  as  the  fetus  advances  in  growth  the  pulsations  become  more 
marked. 

These  pulsations,  whenever  they  can  be  heard,  afford  positive  evi- 
dence of  pregnancy,  yet  their  absence  is  no  indication  of  non-preg- 
nancy, as  the  fetus  may  be  dead,  very  feeble,  or  it  may  be  in  a  position 
unfavorable  to  the  transmission  of  sound  to  the  ear;  or  an  excessive 
quantity  of  the  liquor  amnii  may  destroy  the  sound.  The  presence 
of  twins,  and  even  the  position  of  the  child  in  the  uterus  has  been 
attempted  to  be  determined  by  the  presence  of  these  pulsations,  but 
from  the  discordant  and  contradictory  statements  made  by  authors  in 
relation  to  these  points,  no  confidence  can  be  placed  in  tthem ;  though 
if  the  sound  of  the  fetal  heart  should  be  heard  emanating  from  two 
different  points,  and  especially  when  non-synchronous  in  action,  or  of 
different  rhythm,  it  would  be  of  some  value  in  the  diagnosis  of  twins. 
In  auscultating  a  female  suspected  of  pregnancy,  especially  during  the 
fourth,  fifth  or  sixth  months,  it  is  advisable  to  have  her  lie  upon  her 
back,  with  the  thighs  flexed  upon  the  abdomen ;  the  bed  should  be  of 
a  height  sufficient  to  allow  the  practitioner  to  auscultate  without  stoop- 
ing too  much,  which  would  render  it  impossible  for  him  to  hear  any 
internal  sound.  The  stethoscope,  and  not  the  ear,  should  be  applied 
to  the  abdomen,  which  is  less  disagreeable  to  females,  and  it  should  be 
placed,  first,  over  the  part  where  the  pulsations  are  most  commonly 
heard,  and  then  changed  as  may  be  required. 

The  tangible  signs,  or  those  which  are  ascertained  by  the  touch,  are 
exceedingly  important  in  assisting  us  in  our  diagnosis  of  pregnancy, 
for  by  them  we  are  not  only  enabled  to  determine  this  condition,  but 
also  its  degree  of  advancement;  hence,  every  practitioner  should  fully 
qualify  himself  to  perform  this  operation  of  touching  or  manual  ex- 
amination. 

The  examination  per  vaginam  or  vaginal  touch,  is  usually  made  by 
means  of  the  index  finger,  which  is  always  preferable  to  the  middle 
finger,  as  recommended  by  some  writers;  occasionally,  however,  it 
may  become  necessary  to  introduce  both  index  and  middle  fingers  at 
the  same  time;  this,  however,  is  usually  done  for  the  purpose  of  reacb- 


SIGNS    OF    PREGNANCY.  201 

ing  more  deeply  into  the  vagina,  and  the  touching  should  be  accom- 
plished with  the  index  finger  alone,  for  if  both  are  employed,  there 
may  be  a  double  perception,  and  an  uncertain,  confused  idea  of  the 
condition  of  the  parts  under  examination.  The  practitioner  should  be 
able  to  manipulate  with  either  hand,  as  occasion  should  require,  and 
should  be  very  careful  that  his  finger  nails  are  not  too  long  or  pointed, 
in  order  to  avoid  giving  pain  or  injury,  as  well  as  to  render  the  touch 
more  easy,  delicate,  and  certain ;  long  finger  nails,  in  an  accoucheur, 
manifest  negligence  and  carelessness,  and  are  always  inexcusable.  The 
finger,  in  order  to  admit  of  its  easy  introduction,  should  be  anointed 
with  oil,  lard,  pomatum,  butter,  etc.,  and  not  with  mucilaginous  liquids, 
as  advised  by  many,  because  these  last  do  not  adhere  so  firmly  to  the 
skin,  and  are  less  apt  to  protect  the  finger,  especially  if  there  be  excor- 
iation of  it,  from  the  absorption  of  any  infectious  virus  which  may  be 
present.  As  to  the  length  of  the  finger  necessary  to  become  an  ex- 
pert accoucheur,  that  is  of  little  consequence,  as  the  shortest  fingers 
and  smallest  hands  become,  as  perfect  in  this  art,  as  the  longer  and 
larger. 

The  female  may  be  placed  in  the  erect,  recumbent,  or  sitting  posture, 
according  to  the  circumstances ;  thus,  for  ballotement,  or  for  the  detec- 
tion of  uterine  displacements,  the  erect  position  should  be  assumed ;  to 
ascertain  the  advance  of  pregnancy,  the  size  of  the  uterus,  tumors,  etc., 
the  recumbent  position  is  the  best,  with  the  female  lying  upon  her  back 
or  side;  the  latter  is  preferable  in  these  cases,  with  the  head  and  chest 
elevated  .and  inclined  forward  and  the  inferior  extremities  separated  and. 
flexed  as  much  as  possible  on  the  abdomen,  so  as  to  relax  the  abdom- 
inal muscles,  and  consequently  render  the  examination  more  easy.  In 
some  instances  where  the  erect  position  can  not  be  maintained,  or 
where  the  recumbent  would  give  rise  to  suffocation,  as  in  debility, 
dropsy,  dyspnoea,  etc.,  the  sitting  posture  will  be  found  the  best,  in 
which  the  patient  is  so  placed  upon  a  chair  that  the  weight  of  the  body 
rests  upon  the  sacrum,  the  body  being  inclined  backward  and  the  vulva 
being  beyond  the  edge  of  the  chair,  so  as  to  allow  the  operation  to  be 
performed.  If  the  patient  be  standing,  the  physician  should  -place 
himself  in  front,  resting  on  that  knee  opposite  to  the  operating  hand, 
with  the  other  knee,  demiflexed,  and  placed  between  the  limbs  of  the 
female,  to  act  as  a  support  for  the  elbow  to  lean  upon,  thus  preventing 
the  hand  from  trembling,  and  allowing  the  examination  to  be  made  more 
easily.  If  she  is  in  the  recumbent  position,  he  will  place  himself  on 
that  side  of  his  patient  corresponding  with  the  hand  he  intends  to 
employ,  and  should  be  seated  on  a  chair  of  a  suitable  height.  The 


KIN(i's     KCLKCTK'    OUSTKTKK'S. 

woman,  in  whatever  position  she  may  be  placed,  must  not  be  exposed, 
but  have  a  proper  covering  over  her. 

The  extended  hand  of  the  operator  is  now  to  be  passed  lightly  and 
quickly  along  the  internal  surface  of  the  thigh  nearest  to  him  if  she 
lies  on  her  back — or  of  the  lower  one  if  she  lies  on  her  side — toward 
the  nates,  and  as  soon  as  it  is  arrested  by  the  soft  parts,  and  the  fissure 
between  the  nates  recognized  by  the  index  finger,  this  must  then  be 
carried  forward  toward  the  vulva.  Some  writers  advise  the  finger  to 
be  carried  to  the  symphysis  pubis  and  then  moved  downward  and  back- 
ward; but  in  doing  this,  friction  against  the  clitoris  and  meatus  urin- 
arius  must  necessarily  ensue,  but  which  should  always  be  carefully 
avoided.  The  practitioner  must  be  careful  not  to  commit  an  error  by 
introducing  the  finger  within  the  rectum,  instead  of  within  the  vagina, 
indeed,  this  could  only  happen  from  inattention,  or  an  inexcusable 
carelessness.  On  finding  the  vaginal  opening,  the  condition  of  the 
external  labia,  its  size  and  firmness  must  be  ascertained  by  passing 
them  between  the  thumb  and  index  finger,  and  the  fourchette  may  also 
be  detected  if  there  has  been  no  previous  labor,  but  if  there  has  been, 
it  will  be  absent,  and  its  place  supplied  with  inequalities.  The  finger 
is  then  to  be  pressed  nearly  backward  with  its  palmar  surface  directed 
toward  the  symphysis  pubis,  examining,  as  it  passes  along  the  urethral 
canal,  which  is  generally  more  swollen  in  pregnant  women  than  others, 
the  condition  of  the  mucous  membrane  of  the  vagina,  whether  smooth 
or  wrinkled,  whether  any  abnormal  conditions  of  its  walls  are  present, 
and  the  width  and  length  of  the  vaginal  canal. 

When  about  one-third  of  the  finger  has  passed  into  the  vagina,  the 
wrist  is  to  be  strongly  depressed,  and  the  finger  directed  nearly  verti- 
cal, when  the  bos  fond  of  the  bladder,  the  vaginal  cul-de-sac,  and 
cervix  uteri  may  be  examined.  At  this  time  of  the  operation  the 
thumb  is  to  be  extended  and  applied  against  the  anterior  face  of  the 
symphysis  pubis;  the  other  three  fingers  will  vary  in  position  accord- 
ing to  circumstances,  being  generally  extended  on  the  perineum,  press- 
ing it  upward,  and  sometimes  flexed  with  the  thumb,  into  the  palm  of 
the  hand,  for  the  purpose  of  ballottemeut,  or  for  examining  the  parts 
on  the  anterior  plane. 

However,  if  the  female  lies  upon  her  side,  with  her  back  toward  the 
practitioner,  the  positions  of  the  fingers  will  be  nearly  reversed,  the 
palmar  surface  of  the  index  will  be  looking  toward  the  sacrum,  and  the 
other  fingers  and  thumb  more  or  less  flexed  in  the  palm. 

The  same  method  of  introducing  the  finger  may  be  pursued  for  the 
detection  of  malformations  of  the  pelvis,  the  dilatation  of  the  os  uteri,. 


SIGNS    OF    PREGNANCY.  203 

the  presentation  of  the  fetus,  etc.  The  various  changes  which  the 
neek  of  the  uterus  undergoes  during  pregnancy,  have  already  been 
described,  and  to  which  the  reader  is  referred. 

Abdominal  palpation  or  exploration,  may  assist  us  in  forming  a  cor- 
rect diagnosis  of  pregnancy,  and  can  be  practised  in  all  cases,  with  a 
few  rare  exceptions,  which  may  be  owing  to  an  excessive  thickness  of 
the  abdominal  walls.  In  making  this  examination  the  female  must  be 
placed  in  a  recumbent  position,  on  her  back,  with  the  hips  elevated, 
the  head  flexed  on  the  chest,  and  the  thighs  on  the  abdomen,  which 
position  completely  relaxes  the  abdominal  muscles.  At  first,  both 
hands  are  to  be  applied  over  the  abdomen,  to  determine  its  size,  form, 
and  hardness,  more  especially  in  the  hypogastric  region. 

To  ascertain  the  growth  of  the  uterus,  the  practitioner  will  place  the 
ends  of  the  eight  fingers  immediately  above  the  symphysis  pubis,  and 
make  deep  but  gradual  pressure  until  they  feel  the  resistance  of  the 
uterine  globe ;  and  in  this  manner  he  will  continue  to  ascend  gradually 
along  the  abdomen  until  the  fundus  is  gained,  which  may  be  known 
by  the  absence  of  any  further  resistance,  and  by  the  fingers  sinking 
deeper  and  gliding  over  the  convexity  of  the  fundus.  If  pain  should 
accompany  the  examination,  or  if  the  abdominal  muscles  be  in  a  state 
of  great  tension,  further  procedure  must  be  postponed  until  a  more 
favorable  occasion.  The  uterine  globe  invariably  retains  its  oval  form, 
is  circumscribed,  presenting  a  resistance  somewhat  of  an  elastic  charac- 
ter, and  which  is  firmer  in  the  early  months  of  gestation  than  during 
the  latter;  and  the  practitioner  will  often  be  enabled  to  recognize 
movable,  irregular  masses,  and  even  the  various  parts  of  the  fetus, 
depending  upon  the  period  of  pregnancy  in  which  the  exploration  is 
made.  The  elastic  character  of  the  uterine  partetes  is  not  so  appreci- 
able when  the  enlargement  of  the  organ  is  dependent  upon  chronic 
disease,  and  should  it  be  owing  to  the  presence  of  a  mole  within  its 
cavity,  it  will  be  impossible  to  decide,  unless  at  an  advanced  period, 
when  the  absence  of  the  fetal  movements,  of  the  pulsations  of  the 
heart,  and  of  the  fetal  inequalities,  may  furnish  grounds  for  such  a 
supposition. 

The  vaginal  touch  is  usually  practiced  at  the  same  time  with  the 
abdominal  exploration,  especially  in  the  earlier  months  of  pregnancy. 
The  finger  introduced  within  the  vagina,  is  applied  on  the  neck,  or 
against  that  portion  of  the  uterus  between  the  neck  and  the  symphysis, 
or  between  the  neck  and  the  sacrum,  while  the  other  hand  is  placed 
above  the  pubis,  pressing  firmly  to  recognize  the  uterine  tumor.  The 


204  KING'S   K<M.K<TI<'  OI-.STKTUICS. 

womb  being  tnus  located  between  the  finger  within  and  the  hand  with- 
out, the  degree  of  its  enlargement  may  be  ascertained,  by  instituting 
a  comparison  between  it  and  the  non-gravid  organ.  Again,  the  finger 
may  elevate  the  uterus,  which  will  be  recognized  by  the  hand,  or  the 
hand  may  depress  the  organ,  which  will  be  felt  by  the  finger,  and  thus 
its  condition  and  situation  as  well  as  any  fluctuation,  be  determined. 
However,  during  the  first  three  or  four  months  there  are  no  unequivo- 
cal .signs  of  pregnancy,  and  the  practitioner  will  often  be  mistaken 
should  he  depend  on  any  of  them  at  this  time,  yet  he  may,  in  nearly 
all  instances,  satisfy  himself  of  the  unimpregnated  condition  of  the 
uterus. 

Another  mode  of  determining  the  presence  of  pregnancy,  is  from 
the  passive  movements  of  the  fetus  in  utero,  and  which  is  called  bal- 
lottement; these  motions  depend  upon  physical  laws,  and  are  entirely 
independent  of  the  vitality  and  muscular  strength  of  the  fetus,  as  they 
are  present  whether  it  be  dead  or  alive.  As  a  certain  size  and  weight 
of  the  fetus  is  required  for  ballottement,  it  can  not  be  produced  in  the 
early  months  of  gestation,  or  if  it  can,  it  is  imperceptible.  The  sen- 
sation of  ballottement  is,  according  to  most  writers,  analogous  to  that 
produced  by  striking  a  marble  ball,  which  has  been  placed  in  a  blad- 
der full  of  \vater,  or  in  a  glass  tube  likewise  filled  with  water  sus- 
pended in  a  vertical  position,  with  the  lower  end  closed  by  a  dia- 
phragm of  bladder  or  parchment.  The  blow  is  to  be  given  with  the 
palmar  face  of  the  finger  applied  just  under  the  spot  where  the  ball 
rests,  striking  from  below  upward,  when  the  ball  ascends  in  proportion 
to  the  force  of  the  blow,  and  when  this  force  is  exhausted,  it  descends 
and  falls  back  upon  the  finger  which  displaced  it,  communicating  a 
shock  to  it,  and  which  motion  and  sensation  constitute  ballottement. 

To  perform  the  ballottement,  the  female  should  be  standing,  with 
her  shoulders  placed  against  some  solid  body,  as  a  wall,  to  cause  a 
projection  of  the  abdomen.  The  finger,  properly  oiled,  is  then  to  be 
introduced  into  the  vagina  as  far  as  the  neck,  and  should  be  applied 
anteriorly,  on  that  portion  of  the  uterus  between  the  symphysis  pubis 
and  the  projecting  portion  of  the  neck,  at  which  point  a  smart  blow  is 
to  be  given,  sufficiently  strong  to  cause  the  fetus  to  ascend ;  the  blow 
should  be  made  from  below  upward,  and  from  behind  forward,  which 
last  may  be  effected  by  suddenly  flexing  the  first  phalanx  as  the  shock 
is  imparted.  As  the  uterus  is  generally  inclined  forward  with  its  long 
diameter  corresponding  somewhat  with  the  axis  of  the  superior  strait, 
this  last  direction  of  the  blow  will  be  required  to  cause  the  fetus  to 


SIGNS    OF    PREGNANCY.  205 

ascend  in  the  direction  of  the  uterine  long  diameter,  otherwise,  it  will 
merely  be  pushed  against  the  posterior  wall  of  the  uterus,  being  dis- 
placed without  ascension.  At  the  time  the  blow  is  imparted,  the  op- 
erator should  place  his  other  hand  upon  the  abdomen,  over  the  fundus, 
to  firmly  fix  the  uterus  in  its  position,  and  a  short  time  .after  the  shock 
has  been  communicated  to  the  fetus,  he  will  press  upon  the  fundus  from 
above  downward,  to  hasten  the  descent,  and  thus  increase  the  intensity 
of  the  sensation  to  be  experienced  by  the  finger  within  the  vagina, 
which  finger  is  to  be  held  firmly  and  steadily  against  that  portion  of 
the  uterus  which  has  been  struck,  until  it  has  received  the  shock  of 
the  descending  fetus,  or  until  a  sufficient  length  of  time  has  passed  for 
that  result.  Ballottement  is  best  obtained  when  the  woman  is  in  the 
erect  position ;  yet,  there  may  be  cases  in  which,  from  inability  to 
stand,  the  recumbent  posture  may  be  employed,  when  the  operator  will 
have  to  place  the  finger  at  various  points  both  anterior  and  posterior 
to  the  vaginal  projection  of  the  cervix. 

Ballottement  may  be  effected  at  the  fourth  month  of  utero-gestation, 
though  it  is  frequently  absent  during  this  as  well  as  the  fifth  month ; 
at  the  sixth  or  seventh  month  it  is  very  distinct,  and  conveys  a  sen- 
sation similar  to  that  of  a  solid  ball  inclosed  in  a  fluid  and  falling 
upon  the  finger,  as  above  described.  As  the  fetus  continues  to  grow, 
ballottement  becomes  less  distinct,  is  hardly  perceptible  at  the  end  of 
the  eighth  month,  and  is  impossible  in  the  latter  weeks  of  pregnancy. 
During  the  early  period  of  ballottement  it  may  be  advisable,  in  cases 
where  accuracy  is  absolutely  required,  and  in  which  it  can  not  be 
recognized,  to  make  several  trials ;  as  from  the  fact  that  the  small  size 
of  the  child  allows  it  to  easily  change  its  position,  this  sign  may  be 
present  one  day,  and  be  quite  impossible  to  detect  at  another. 

By  many  authors  ballottement  is  considered  as  a  pathognomonic 
symptom  of  pregnancy,  being  equally  applicable  to  the  dead  or  living 
fetus,  and,  indeed,  we  know  of  no  other  cause  to  produce  it,  than  the 
actual  presence  of  a  child  within  the  uterus.  However,  the  practi- 
tioner should  always  ascertain  that  there  is  no  displacement  of  the 
uterus  which  might  create  a  mistake,  as  in  anteversion,  and  also  that 
the  shock  communicated  to  his  finger  is  not  from  stone  in  the  bladder; 
each  of  these  conditions,  has,  heretofore,  occasioned  some  difficulty  in 
determining  true  ballottement. 

From  what  has  been  stated,  it  will  be  observed,  that  in  order  to 
determine  the  condition  of  pregnancy  with  certainty,  the  practitioner 
will  be  obliged  to  procure  a  delay  until  the  motions  of  the  fetus  and 


20G  Ki.\(i's   KCI.KCTIC  <»I;STI-:TI;I<  s. 

other  signs  :irc  manifested  with  force  and  distinctness,  and  which 
usually  will  beat  the  fourth  or  fifth  month;  though,  from  feebleness  of 
the  fetus  he  may  have  to  wait  for  a  still  longer  period.  In  all  difficult 
cases,  the  physician,  when  called  upon,  should  never  positively  aHiriu 
the  existence  oil  pregnancy,  until  he  has  distinctly  perceived  the  pul- 
sations of  the  fetal  heart,  ballottement,  and  the  proper  changes  in  the 
condition  of  the  uterus;  in  ordinary  cases,  an  experienced  practitioner 
can  form  a  correct  diagnosis  from  these  last  uterine  changes;  the  ra- 
tional signs  afford  but  little  evidence  of  any  value  or  certainty. 

Occasionally,  the  physician  is  called  upon  to  determine  the  stage  of 
pregnancy  ;  this  is  often  very  difficult.  However,  reference  should  be 
had  to  the  length  of  time  which  has  elapsed  since  the  last  menstrua- 
tion, the  position  of  the  fundus  uteri,  the  condition  of  the  cervix, 
ballottement,  auscultation,  and  the  time  of  quickening,  if  it  have 
taken  place,  and  from  all  which,  an  approximation  to  the  period  of 
gestation  may  be  obtained.  As  to  the  sex  of  the  fetus  in  utero, 
I  know  of  no  method  of  determining  it ;  Drs.  T.  J.  Hutton  and 
Braxton  Hicks  have  stated,  however,  that  this  may  be  determined 
in  most  cases  by  auscultation  practised  toward  the  end  of  pregnancy. 
If  the  fetal  pulsations  number  from  138  to  144,  the  child  is  probably 
a  female;  from  124  to  130  it  is  probably  a  male.  Steinbach  was 
correct  in  45  out  of  57  cases  examined  by  this  method,  and  Franken- 
hauser  was  correct  in  all  the  50  cases  which  he  examined.  And  Dr. 
Hutton  further  remarks  that  if  the  uterus  be  divided  into  two  equal 
parts  by  an  imaginary  horizontal  line,  fetal  pulsations  heard  below 
this  line  indicate  a  presentation  of  the  vertex ;  above  it,  of  the  nates ; 
and  below  it  and  to  the  right,  of  the  second  vertex  position.  Neither 
is  there  any  reliable  mode  of  ascertaining  the  presence  of  twins, 
further  than  already  stated. 

SYNOPSIS  OF  THE  SIGNS  OF  PREGNANCY  AT  DIFFERENT  STAGES. 
During  the  First -and  Second  Months. 

RATIONAL  SIGNS.  SENSIBLE   SIGNS. 

1.  Suppression   of  the  catamenial  dis-  1.  Increase  in  the  size  and  weight  of  the 
charge.  uterus,   with    slight  prolapsus.     The  cer- 

2.  Nausea,   vomiting,    ptyalisra,    anor-  vix  uteri  is  directed  to  the  left  and  toward 
exia,  etc.  the  symphysis  pubis,  fluctuation,  increased 

3.  Unnatural  flatness  over  the  hypogas-  temperature, 
triurt. 


CHANGES    IN    THE    UTERUS    DURING    I'UKCXANCY. 


•207 


RATIONAL    SIGNS. 


4.  Tumefaction 
mammae. 


and  tenderness  of  the 


SENSIBLE   SIGNS. 

2.  Diminished    mobility   of   the   uterus, 
its  walls  soft  like  caoutchouc. 

3.  The  os  uteri   round   and  regular  in 
primiparse,  but  in  mnltiparse,  irregular  in 
its  circumference  and  more  or  less  open. 

4.  Eamollissement  and  apparent  oedema 
of  the   mucous    membrane,  covering  the 
lips  of  the  cervix  uteri.     The  fibers  of  the 
neck  not  vet  softened. 


During  the  Third  and  Fourth  Months. 


1.  Suppression  of  the  catamenia  (an  oc- 
casional exception).  ' 

2.  Continuance  of  nausea,  vomiting,  an- 
orexia, ptyalism. 

3.  Slight  prominence  over  the  hypogas- 
trium. 

4.  Depression  of  the  umbilicus. 

5.  Tumefaction  of  the  breasts  increased, 
with   prominence   of    the   nipple,   and    a 
Blight  discoloration  of  the  areolse. 

6.  Kiesteine  in  the  urine.  ? 


1.  The    fundus    uteri    elevated    rather 
above  the  superior  strait,  at  the  end  of  the 
third  month.     At  the  termination  of  the 
fourth  month,  it  rises   two  or  two  and  a 
half  inches  above  the  pubis. 

2.  Fullness,  and  dullness  on  percussion 
over  the  hypogastrium. 

3.  Existence  of  a  small   tumor  in  the 
hypogastric  region,  detected  by  abdominal 
palpation,  about  the  size  of  a  child's  head 
a  year  old. 

4.  The  direction  of  the  long  diameter  of 
the  uterus  is  now  changed,  so  as  to  cor- 
respond  with   the   axis   of   the   superior 
strait.     At  the  fourth  month  the  os  uteri 
is  considerably  elevated  in  the  excavation, 
looking   backward    and    to   the    left;    in- 
creased temperature. 

5.  Ramollissernent  of  the  inferior  por- 
tion  of  the  cervix  is  more  marked  ;   os 
uteri  more  open  in  the  multiparae,  but  still 
closed  and  rounded  in  those  who  have  not 
borne  children. 


During  the  Fifth  and  Sixth  Months. 


1.  Suppression  of  the  catamenia.    (Some 
rare  exceptions.) 

2.  Cessation   of  nausea,  vomiting,  etc., 
now  usually  takes  place,  though  they  may 
continue  throughout  pregnancy. 

3.  Increased  prominence  of  the  sub-um- 
bilical region. 

4.  The  size  of  the  abdominal  tumor  is 
increased,  it  is  round,  elastic,  and  if  the 
abdominal  walls  be  thin,  the  inequalities 
of  the  fetus  may  be  felt. 


1.  At  the  end  of    the  fifth  month,  the 
fundus  uteri  is  within  an  inch  of  the  um- 
bilicus, and  the  same  distance  above  it  at 
the  sixth. 

2.  Movement  of  the  fetus  is  now  active. 

3.  The  bruit  de  souffle  and  the  fetal  pul- 
sations may  now  be  distinguished. 

4.  Ballottement. 

5.  Between  the  cervix  and  the  pubis  z 
tumor   may  now  be   felt,  either  soft   and 
fluctuating,  or  round,  hard,  and  resisting. 


208 


KING'S  ECLECTIC  OBSTETRICS. 


RATIONAL   SIGNS. 

5.  The  umbilical  depression  nearly  ef- 
faced. 

6.  Discoloration    of    the    areolae   more 
marked,  with  an  enlargement  of  the  sub- 
cutaneous glands. 

7.  Kiesteine  in  the  urine.  ? 


SENSIBLE   SIGNS. 

6.  Ratnollissement  of  the  inferior  half 
of  the   cervix   uteri ;   increased   tempera- 
ture. 

7.  In  the  primiparse,  the  os  uteri  is  still 
closed,  but  in    the   multipart,  it   is  suffi- 
ciently open  to  admit  the  half  of  the  first 
phalangeal  bone,  although  in   each  it  is 
softened  to  the  same  extent. 


During  the  Seventh  and  Eighth  Months. 


1.  Suppression  of  the  catamenia. 

2.  Nausea,  vomiting,  etc.,  ordinarily  ab- 
sent • 

3.  Abdominal  tumor  much  increased  in 
size. 

4.  Dilatation  of  the  umbilical  ring,  and 
pouting  of  the  navel. 

5.  Increased  discoloration  of  the  areolse, 
with  enlargement  of  the  sebaceous  folli- 
cles, and  increased  prominence  of  the  nip- 
ple.    The  milk  may  be  pressed  from  the 
swollen  mammae. 

6.  Discolorations  on  the  skin  of  the  ab- 
domen. 

7.  Vaginal-granulations. 

8.  Kiesteine  still  exists  in  the  urine.? 


1.  Increased  size  of  the  abdomen. 

2.  The  fundus  uteri,  at  the  end  of  the 
seventh  month,  has  risen  two  and  a  half 
inches  above  the  umbilicus;  at  the  eighth, 
it  is  placed  within  the  epigastric  region  ; 
uterus  commonly  inclined  to  the  right. 

3.  Movements  of  the  fetus  become  more 
violent. 

4.  The  fetal  pulsations  and  the  bruit  de 
souffle  still  continue. 

5.  Ballottement  perfectly  felt  during  the 
seventh   month,  but  becomes   obscure    in 
the  subsequent  months   of  pregnancy,  on 
account  of  the  increase  in  the  size  of  the 
fetus. 

6.  The  ramollissement  of  the  cervix  is 
more   extensive,  and    at   the   end   of  the 
eighth    month    is    nearly   complete;    in- 
creased temperature. 

7.  In  the  primiparae,  the  cervix  is  ovoid 
and  apparently  shortened ;  the  os  uteri  is 
still  closed. 

8.  In  the  multipart,  the  os  uteri  is  co- 
noidal  and  wide  enough  open  to  admit  the 
whole  of  the  first  phalangeal  bone  ;   the 
superior  fourth  of  the  neck  still  hard  and 
firmly  closed. 


During  the  First  Half  of  the  Ninth  Month. 


1.  Reappearance  of  vomiting,  not  from 
nausea   but  from   pressure  of  the  gravid 
uterus  against  the  stomach. 

2.  The   abdominal    tumor  is   increased 
in  size ;  skin  much  stretched  and  tense. 

3.  Respiration  difficult. 

4.  All  the  other  symptoms  remain  and 
are  augmented  in  intensity. 


1.  The  fundus  uteri  occupies  the  epigas- 
tric region. 

2.  The    movements   of    the    fetus;    the 
pulsation  of  the  fetal  heart  and  bruit  de 
souffle  are  still  present.     At  this  time  bal- 
lottement  has  disappeared. 

3.  The  whole  cervix  uteri   is  softened, 
except  the  internal  orifice,  which  remains 


CHANGES    IN    THE    UTERUS    DURING    PREGNANCY.  209 

RATIONAL    SIGNS.  SENSIBLE  SIGNS. 

firm  and  closed.  The  os  uteri  in  primi- 
parse  is  slightly  opened,  though  not  suffi- 
ciently to  admit  the  finger,  as  in  the  case 
in  multiparse,  although  the  softening  is 
equally  extensive  in  each ;  increased 
temperature. 

During   the   Last   Half  of  the   Ninth  Month. 


1.  The  vomiting  ceases,  as  the  abdom- 
nal  tumor  sinks  from  the  epigastrium. 

2.  Respiration  less  oppressed. 

3.  Considerable  difficulty  exists  in  walk- 
ing, owing  to  the  sinking  of  the  presenting 
part  into  the  pelvic  excavation. 

4.  Constant    and    ineffectual    desire  to 
evacuate  the  bladder  and  rectum. 

5.  The  hemorrhoids,  the  oedema  of  the 
limbs  and   the  varicose    condition  of  the 
veins  of  the  inferior  extremities   are    all 
increased. 

6.  Pains  in  the  loins,  and  colics. 


1.  The  fundus  uteri  has  sunk  low  down 
in  the  abdomen. 

2.  The  sensible  signs  still  persist,  except 
ballottement,  which  is  usually,  though  not 
always,  absent  after  the  fetus  has  acquired 
considerable  size. 

3.  In  multiparse,  the  internal  orifice  of 
the  cervix  is  softened  and  dilated,  so  that 
the  membranes  may  be  felt.  In  the  primi- 
parae,   the  internal  orifice   is  soft  and  di- 
lated, but  the  external  remains  partially 
closed.     During    the   last  ten    or    twelve 
days,  owing  to  the   dilatation   of  the    in- 
ternal   orifice   of  the    cervix     uteri,   the 
whole   cavity   of  the    neck    becomes  en- 
larged, so  as  to  increase    the  size  of  the 
uterine  cavity;  so   that   in   touching,    the 
finger    reaches    the   membranes,    in    the 
primiparse,  after  having  passed  the    thin 
and  even  margin  of  the  os  uteri.     While 
in  the  multiparse,  this  margin  is  thick  and 
unequal. 


CHAPTER   XXI. 

DISEASES    OF    THE    PREGNANT    FEMALE. 

BETWEEN  the  uterus,  and  every  part  of  the  body,  a  strong  nervous 
sympathy  exists,  owing  to  the  intimate  relation  maintained  between 
the  sympathetic  and  cerebro-spinal  system  of  nerves ;  and  this  sym- 
pathy is  more  especially  marked  during  the  condition  of  pregnancy, 
when  the  ganglia  and  plexuses  of  nerves,  together  with  the  blood- 
vessels and  absorbents  of  the  uterus  enlarge,  and  become  roused 
from  a  state  of  apparent  inertia  to  one  of  energetic  activity.  This 
change  in  the  female  system  gives  rise  to  many  symptoms,  which  may 
14 


210  KING'S  ECLECTIC  OBSTETRICS. 

be  considered  as  indications  of  the  healthy  act  of  conception,  a;;<l 
which, as  a  general  rule,  should  not  be  meddled  with;  but,  when  they 
Ixrome  unusually  severe  or  protracted,  they  are  then  termed  the  "dis- 
eases of  i>n •u'liancy,"  and  require  proper  treatment  for  their  palliation 
or  removal.  As  pregnant  females  are  liable  to  the  same  diseases  as 
the  unimpregnated,  it  would  require  a  volume  to  treat  separately  upon 
them ;  I  shall,  therefore,  confine  this  part  of  the  subject  to  those  con- 
diti  >ns  more  common  during  pregnancy. 

When  the  female  is  supposed,  from  the  presence  of  the  ordinary 
symptoms,  to  have  become  pregnant,  certain  measures  are  necessary 
for  her  to  pursue,  as  well  for  her  own  benefit  as  for  that  of  her  off- 
spring. All  compression  upon  the  abdomen  or  around  the  waist,  such 
as  stays,  corsets,  belts,  etc.,  should  be  removed,  modified  or  worn 
loosely,  and  should  not  be  resorted  to  until  after  parturition;  an  at- 
tention to  this  point  may  prevent  abortion,  varices,  oedema,  uterine, 
and  other  disease,  on  the  part  of  the  mother,  which  difficulties  are 
very  apt  to  be  the  result  of  pressure  and  consequent  obstruction  of  the 
portal  circulation,  as  well  as  of  the  great  arterial  trunks  and  veins  of 
the  abdomen ;  and  on  the  part  of  the  fetus,  hydrocephalus,  deformity, 
or  positions  which  may  render  the  labor  tedious  and  even  fatal.  She 
should  likewise  be  especially  observant  of  her  diet,  selecting  that 
which  is  the  most  nutritious  as  well  as  most  easily  digested,  bearing 
in  mind,  that  the  gastro-uterine  sympathy,  as  well  as  the  gradually 
increased  volume  of  the  uterus,  tend  greatly  to  diminish  the  energy 
of  the  digestive  powers.  Stimulants  especially,  as  alcoholic,  vinous, 
or  malt  liquors,  fats,  much  acidulous  food,  and  in  instances  where 
they  prove  decidedly  hurtful,  tea  and  coffee,  are  to  be  avoided.  The 
use  of  farinaceous  vegetables,  ripe  fruits,  boiled  or  roasted  meats, 
water,  and  milk,  may  be  named  as  among  the  best  kinds  of  food  and 
drink ;  and,  though  many  females  may  have  indulged  their  appetites 
without  any  resulting  unpleasant  symptoms,  yet  such  a  course  is  more 
apt  to  produce  various  difficulties  than  is  generally  supposed,  especially 
upon  the  future  of  the  fetus.  Moderate  exercise  in  the  open  air,  espe- 
cially during  the  early  months  of  pregnancy,  should  be  very  strongly 
advised,  with  only  occasional  and  not  too  prolonged  bathing.  Coition, 
though  commonly  indulged  in  during  pregnancy,  is  extremely  unwise 
and  improper;  and  though  often  practiced  with  impunity,  yet  it  is  very 
apt  to  be  followed  by  metrorrhagia,  abortion,  or  some  defect  in  the 
mental  or  physical  organization  of  the  offspring.  Females  subject  to 
leucorrhea,  immoderate  menstrual  evacuations,  abortions,  as  well  as 


DISEASES    OF    THE    PREGNANT    FEMALE.  211 

those  of  a  nervous  or  impressible  temperament  should  be  particularly 
warned  against  cohabitation  during  pregnancy.  If  parents  desire 
physically  and  mentally  healthy  offspring,  the  sexual  passion  must  be 
permitted  to  remain  dormant  or  undisturbed  during  the  period  of  ges- 
tation. The  symptoms  or  diseases  of  pregnancy,  which  frequently 
require  medical  treatment,  are  first,  those  which  are  the  result  of  de- 
ranged circulation  and  nervous  sympathy;  second,  those  originating 
from  the  compression  of  the  enlarged  uterus  upon  the  neighboring 
organs;  third,  diseased  conditions  of  the  uterus  or  its  contents;  aod 
fourth,  accidental  diseases. 

Among  those  symptoms  depending  probably  upon  deranged  circu- 
lation and  nervous  sympathy,  one  of  the  most  common,  as  well  as  the 
earliest,  is  vomiting,  or  morning  sickness,  as  it  is  usually  termed.  Vari- 
ous explanations  have  been  given  from  time  to  time  as  to  the  cause  of 
this  phenomenon,  but  none  of  them  are  wholly  satisfactory.  With  the 
major  part  of  females  it  is  the  first  sign  of  pregnancy,  commencing 
usually  about  the  fourth  or  sixth  week,  and  sometimes  immediately 
after  conception,  and  continuing  for  a  few  months,  or  even  up  to  the 
parturient  period.  It  partakes  of  the  character  of  sea-sickness,  or  of 
that  experienced  by  persons  commencing  to  smoke  tobacco.  The 
female  experiences  more  or  less  nausea  from  the  time  of  rising  in  the 
morning,  which  may  at  first  be  removed  by  eating  the  morning  meal, 
but  which  soon  becomes  followed  by  vomiting  of  a  greater  or  less 
degree  of  severity  and  duration;  occasionally,  the  vomiting  becomes 
exceedingly  violent,  everything  being  rejected  from  the  stomach,  and 
if  not  checked,  the  female  may  die  from  exhaustion  or  starvation ;  or 
premature  labor  may  ensue,  followed  by  hemorrhage  of  an  alarming 
character.  Where  the  vomiting  occurs  during  the  first  three  or  four 
months  of  pregnancy  it  is  dependent  upon  gastro-uterine  sympathy — 
is  principally  confined  to  the  morning,  lasts  from  ten  minutes  to  an 
hour  or  two,  each  day,  and  usually  ceases  in  from  two  to  four  months; 
the  matter  evacuated  is  thick,  slimy,  colorless,  greenish  or  blackish, 
frequently  acid,  and  if  the  effort  at  vomiting  be  severe,  a  little  bile  or 
even  blood  may  be  mixed  with  it.  This  sympathetic  vomiting  seldom 
falls  under  the  practitioner's  care,  unless  it  becomes  very  severe ;  and 
indeed,  no  especial  means  are  required  for  its  removal  when  not  too 
violent  or  prolonged,  as  it  is  merely  a  normal  effect  of  conception. 

When  the  vomiting  occurs  only  in  the  morning,  and  is  compara- 
tively slight,  it  may  be  palliated  by  some  aromatic  infusion,  and  if  the 
discharges  are  very  acid,  magnesia,  alkalies,  with  aromatics,  or  char- 


212  KINO'S    KCLKCTIC    OBSTETRICS. 

coal,  will  bo  found  efficient;  sometimes  these  agents  will  exert  but 
little  effect  upon  the  acidity,  in  which  cases,  they  will  have  to  be  laid 
aside  and  acids  employed,  as  Lemon-juice  and  water,  a  solution  of 
Tartaric  or  Citric  acid,  or  acid  wines.  Should  the  discharges  contain 
much  bile,  mild  cholagogue  laxatives  will  be  found  beneficial,  as  a 
combination  of  two  parts  of  Rhubarb  and  one  of  Bicarbonate  of  Po- 
tassa,  administered  three  times  a  day,  in  doses  of  eight  or  ten  grains 
of  the  mixture,  or  sufficient  to  produce  one  or  two  mild  alvine  evacu- 
ations, daily;  may  also  use  Citrate  of  Magnesia,  or  Seidlit/  powders. 
When  the  vomiting  is  accompanied  with  much  pain  in  the  stomach, 
Sp.  Tr.  Nux  Vomica  or  Ignatia,  with  counter-irritation  to  the  epigas- 
tric region,  may  be  employed  with  advantage ;  and  in  severe  and  ob- 
stinate cases  of  pain  I  have  succeeded  in  giving  relief,  when  other 
means  have  proved  inutile,  by  applying  a  hot  fomentation  of  water 
over  the  epigastrium,  together  with  hot  sponging,  Chloroform,  Aqua 
Ammonise,  or  a  Sinapism. 

When  the  vomiting  is  violent  and  obstinate,  various  means  have 
been  advised,  all  of  which  have  at  times  proved  beneficial;  it  must  be 
remembered,  that  while  a  certain  course  may  produce  a  good  influence 
on  one  patient,  it  may  have  no  effect  whatever  upon  another,  hence 
the  necessity  of  an  acquaintance  with  these  several  means.  As  severe 
vomiting  is  frequently  accompanied  with  gastric  or  hepatic  derange- 
ment, Chionanthus  or  the  small  Podophyllin  pill  often  controls  it. 
Macrotys  will  control  a  larger  number  of  these  cases  than  any  other 
single  agent,  and  though  it  may  fail  in  the  beginning,  I  often  pre- 
scribe it  again,  after  having  exhausted  the  list  of  remedies,  and  in 
this  way  frequently  succeed;  Pulsatilla  is  also  a  good  agent,  especially 
when  nervous  excitation  is  present.  They  may  be  used  singly,  in 
alternation,  or  together.  Jn  cases  where  the  circumstances  of  the  pa- 
tient will  allow,  Champagne  wrine,  according  to  Prof.  Meigs,  taken 
during  the  meal  (should  vomiting  occur  after  the  meal)  will  almost 
always  prevent  it.  I  have  occasionally  met  with  severe  cases  of  vom- 
iting, in  which,  after  the  employment  of  the  usual  remedies  without 
effect,  Lobelia  has  produced  the  desired  influence ;  in  such  cases,  I  have 
rubbed  together  one  drop  of  Oil  of  Lobelia  and  thirty  grains  of  Sugar, 
and  given  one-sixth  of  the  mixture  for  a  dose,  repeating  it  every  ten 
or  fifteen  minutes  until  relief  ensued,  which  generally  followed  the 
first  or  second  dose,  rarely  requiring  a  third  or  fourth.  Notwithstand- 
ing all  these  remedies,  it  will  happen,  sometimes,  that  no  relief  will 
be  experienced,  and  the  patient  continues  to  suffer  up  to  the  fourth 


DISEASES    OF   THE    PREGNANT    FEMALE.  213 

month  without  any  amelioration  of  her  condition;  yet,  even  in  such 
cases,  the  physician  should  not  add  to  her  suffering  by  giving  up  the 
case  as  beyond  remedial  action,  but  should  cheer  her  up,  and  endeavor 
to  fortify  her  spirits  by  the  anticipation  of  better  effects  from  the  next 
means  to  be  used.  In  some  instances  food  is  only  retained  while  cold; 
and  in  others  nothing  will  lie  on  the  stomach  but  what  is  hot.  Ice 
will  sometimes  check  it,  and  bismuth  has  a  good  effect.  Effervescing 
draughts  have  been  extolled  in  attempts  to  allay  the  sickness,  and  will 
often  give  satisfactory  results,  as  Seidlitz  powders,  Soda  or  Mineral 
water. 

The  use  of  peptics  is  to  be  commended. 

Acidulated  camphor  water  makes  a  pleasant  drink,  and  will,  in 
some  cases,  control  a  rebellious  stomach,  where  other  agents  fail; 
Fowler's  solution  of  arsenic,  administered  in  drop  doses  on  an  empty 
stomach,  or  with  a  restricted  diet, .has  been  highly  commended.  I 
have  succeeded  in  overcoming  obstinate  cases,  in  several  instances, 
by  the  use  of  Macroty's  and  Fowler's  solution  in  alternation.  Prof. 
Howe  speaks  of  the  alternate  use  of  these  agents,  and  says  he  has  long 
considered  arsenic  as  the  specific  for  the  vomiting  of  pregnancy. 
Many  other  agents  have  been  used  and  recommended  for  this  dis- 
tressing symptom,  as  Bromide  of  Potassium,  Creosote,  Turpentine, 
Salicin,  Lime  water,  Oxalate  of  Cerium,  and  infusions  of  Peach  and 
AVild  Cherry-tree  bark,  etc.,  etc.  In  fact,  there  is  scarcely  anything 
considered  remedial  that  has  not  been  tried  in  the  vomiting  of  preg- 
nancy. 

In  persistent  nausea,  with  inability  to  retain  any  kind  of  food  on  the 
stomach,  and  having  exhausted  the  list  of  internal  remedies,  I  have 
succeeded  in  subduing  the  trouble,  temporarily,  or  until  food  could  be 
taken,  by  the  hypodermic  injections  of  Morphia.  Dr.  Girabetti  states 
that  he  has  successfully  treated  obstinate  cases  of  this  character  by 
rectal  injections  of  solution  of  Bromide  of  Potassium,  commencing 
with  90  grains  of  the  salt  the  first  day;  120  the  second;  and  150  the 
third  day — and  then  lessening  the  dose  in  proportion  to  the  effect. 
Dr.  Simmons  has  met  with  a  similar  success  by  rectal  injections,  morn- 
ing and  evening,  of  a  solution  in  mucilage  of  30  or  40  grains  of  Hy- 
dro-chloral. We  do  not  commend  such  heroic  measures,  however, 
believing  milder  means  to  be  more  effectual.  Carbolic  acid,  in  the 
dose  of  from  one-fourth  to  one-half  a  grain,  in  a  teaspoonful  of  glyc- 
erine or  mucilage,  and  repeated  three  times  a  day,  has  likewise  proved 
effectual  in  certain  cases,  especially  when  gastric  acidity,  flatus,  or  fer- 


214  KING'S  ECLECTIC  OBSTETRICS. 

mentive  dyspepsia  was  present.  In  all  these  cases,  the  diet  should  be 
of  the  lightest  character,  and  if  the  stomach  be  found  to  possess  less 
irritability  at  any  certain  period  of  the  day,  this  period  must  be  selec- 
ted for  taking  the  principal  meal.  The  practitioner  must  likewise 
ascertain  whether  fluid  or  solid  food  agrees  best  with  the  stomach,  and 
advise  the  patient  accordingly.  The  patient  should  not  move  about 
too  much,  and,  sometimes,  rest  in  the  horizontal  position  will  be  ab- 
solutely required.  Gastritis,  indigestible  food,  constipation,  certain 
odors,  etc.,  may  likewise  give  rise  to,  or  increase  the  severity  of  vom- 
iting during  uterogestation,  all  of  which  should  be  borne  in  mind 
during  treatment,  that,  if  present  as  existing  causes,  they  may  be 
removed.  . 

Where  vomiting  occurs  only  during  the  early  part  of  the  day,  Prof. 
Meigs  recommends  a  cup  of  coffee  with  toast,  to  be  taken  by  the 
patient  while  in  bed,  after  which  she  should,  if  possible,  sleep  again 
for  a  short  time ;  upon  subsequently  arising  no  nausea  or  vomiting 
will  take  place.  I  have  tested  this  method,  and  found  it  to  succeed 
admirably  in  the  majority  of  cases.  Hot  milk,  or  hot  water,  will 
prove  serviceable  when  preferred  to  coffee. 

In  some  cases  recently  seen  in  consultation  with  other  physicians, 
where  the  usual  remedies  had  been  tested,  I  relieved  vomiting  by 
local  applications  to  the  neck  of  the  pregnant  wromb.  A  solution  of 
cocaine  —  two  grains  to  the  fluid  drachm  of  water — I  believe  to  be  the 
best  local  agent.  The  patient  can  wet  a  piece  of  lint  with  the  solu- 
tion, and  carry  it  to  the  os  uteri  every  six  to  eight  hours.  The  fluid 
extract  of  Veratrum  viride,- incorporated  with  vaseline  and  applied  to 
.the  os  uteri,  will,  it  is  claimed,  produce  about  the  same  effect  as 
cocaine.  The  local  use  of  Tinct.  Iodine,  and  the  application  to  the 
cervix  uteri  of  colorless  Iodine,  have  given  very  satisfactory  results. 
The  practice  of  dilating  the  neck  of  the  uterus  has  many  able  advo- 
cates. The  cervix  is  to  be  dilated  to  £he  depth  of  near  a  half  inch. 

Good  results  have  followed  in  several  cases,  in  which  the  cervix  was 
dilated  by  means  of  a  small  silk  sponge  saturated  with  the  cocaine 
solution. 

The  vomiting  that  occurs  after  the  fourth  month  of  pregnancy  is 
supposed  to  be  owing  to  the  pressure  of  the  gravid  uterus  upon  the 
stomach,  and  is  often  very  difficult  to  relieve ;  indeed,  palliation,  as 
the  rule,  is  all  that  can  be  expected.  Tonics,  and  antispasmodics  may 
be  employed  in  these  cases.  I  have  frequently  met  with  cases  which 
resisted  all  treatment,  ceasing  only  at  parturition ;  and  again,  I  have 


DISEASES    OF    THE    PREGNANT    FEMALE.  215 

considerably  mitigated  the  severity  of  this  distressing  symptom,  by 
keeping  the  bowels  in  a  regular  condition  preventing  constipation,  and 
administering  the  small  doss  of  macrotys ;  relieving  the  irritable  stom- 
ach to  such  an  extent,  within  a  short  time,  as  to  retain  light  food. 
The  application  of  coacine  becomes  valuable,  and  more  often  called 
for  in  sickness  occurring  after  the  fourth  month,  than  before  that  time  ; 
and  should  be  remembered  as  an  agent  soothing  and  kindly  in  its 
action;  often  relieving  when  internal  remedies  are  not  tolerated. 
Counter-irritation  over  the  last  dorsal  vertebrse  is  often  a  valuable 
adjunct  to  the  treatment.  In  this  form  of  vomiting,  all  food,  or  what- 
ever is  received  into  the  stomach  is  generally  rejected,  and  the  patient 
suffers  from  inanition;  indeed,  the  principal  subject  of  fear  is,  that 
she  may  die  from  actual  starvation.  It  should  be  our  aim  to  discover 
what  variety  of  food  best  agrees  with  the  stomach,  and  the  period  cf 
the  day  in  Avhich  this  organ  is  the  least  irritable,  that  advantage  may 
be  taken  of  that  period  for  taking  a  light  meal.  In  some  instances 
where  vomiting  followed  the  reception  of  everything  taken  into  the 
stomach  even  in  moderate  quantity,  I  have  succeeded  in  sustaining 
the  powers  of  the  patient  up  to  the  period  of  parturition,  by  giving 
half-teaspoonful,  or  teaspoonful  doses  of  milk,  cream,  gruel,  etc.,  every 
hour  or  two  throughout  the  day,  occasionally  with  a  few  drops  of 
Brandy,  or  other  stimulant  added.  In  one  case,  ice  cream  was  all  in 
the  way  of  food  that  could  be  taken  for  a  number  of  days,  and  proved 
very  serviceable  in  tiding  the  patient  along  until  more  substantial 
nourishment  could  be  taken.  •  In  extreme  cases,  where  all  forms  of  food 
are  ejected  by  the  stomach,  rectal  alimentation  may  become  necessary. 
The  whites  of  two  eggs,  in  eight  ounces  of  water,  may  be  injected 
every  six  or  eight  hours.  In  these  cases,  the  less  medicine  the  patient 
swallows,  the  better  will  it  be  for  her,  except  when  imperiously  de- 
manded. 

Frequently  the  vomiting  becomes  so  excessive  as  to  threaten  the 
life  of  the  patient,  as  before  observed,  from  starvation;  for  it  is  sel- 
dom the  case  that  abortion  is  produced  by  puerperal  nausea,  though 
it  frequently  ensues  from  emetics.  In  such  instances,  after  a  fair  and 
patient,  but  fruitless  trial  of  all  remedies  to  overcome  the  difficulty, 
and  sustain  the  patient's  strength,  we  may  be  compelled  to  resort  to 
premature  delivery.  This,  however,  is  not  to  be  thought  of,  unless, 
the  patient's  life  is  actually  endangered,  and  should  never  be  under- 
taken without  having  first  consulted  with  one  or  more  medical  men. 
Dubois,  who  in  the  course  of  thirteen  years  met  with  twenty  fatal 


216  KING'S  ECLECTIC  OBSTETRICS. 

cases,  advises  never  to  perform  the  operation,  even  though  the  vomit- 
ing be  violent,  when  the  patient,  however  feeble  and  emaciated  she 
may  be,  is  not  obliged  to  retain  her  bed,  when  a  small  portion  of 
aliment  can  be  retained,  and  when  intense  and  continuous  febrile 
action  has  not  been  induced;  he  also  prohibits  the  operation  when 
signs  of  extreme  exhaustion  are  present,  as  loss  of  vision,  cephalalgia 
coma,  somnolence,  and  mental  disorder.  A  timely  interference  is 
advised,  at  a  period  characterized  by  an  incessant  vomiting,  whereby 
all  food,  and  sometimes  even  a  drop  of  water  is  rejected ;  where 
emaciation  and  debility  are  present,  requiring  absolute  rest ;  where 
the  least  movement  or  mental  emotion  causes  syncope;  where  .the 
features  become  decidedly  changed ;  where  there  is  severe  and  con- 
tinuous febrile  action,  with  excessive  and  penetrating  acidity  of  the 
breath,  and  a  failure  of  all  other  means.  Dr.  Churchill  considers  the 
pulse  to  be  the  best  guide;  and  when  this  rises  there  should  be  no 
hesitation  in  at  once  producing  an  abortion,  lest  the  patient  may 
become  so  far  prostrated,  from  a  delay,  as  to  render  death  certain. 

When  vomiting  has  been  very  distressing  during  labor,  I  have 
frequently  given  prompt  relief  by  the  administration  of  the  tincture 
of  Gelsemium,  and  would  suggest  its  employment  in  these  obstinate 
vomitings  during  pregnancy. 

Ptyalism  or  salivation,  frequently  occurs  during  the  early  months 
of  gestation,  and  seldom  requires  any  treatment.  Rarely,  however, 
it  becomes  very  severe,  resembling  mercurial  ptyalism,  but  differing 
from  this  in  the  absence  of  tenderness  of  the  gums  and  disagreeablei 
fetor  of  the  breath ;  the  fluid  secreted  is  colorless  and  transparent,  or 
tenacious  and  frothy,  with  an  unpleasant  taste,  commonly  accompanied 
with  acidity,  and  often  inducing  vomiting.  As  a  general  rule,  this 
symptom  needs  no  treatment.  Phytolacca  or  Hamamelis,  However, 
should  be  thought  of  when  treatment  becomes  necessary ;  a  good 
plan  is,  to  regulate  the  action  of  the  bowels  by  mild  aperients,  and 
wash  or  gargle  the  mouth  and  throat  with  Borax  water.  I  have 
never  had  this  symptom  to  contend  with,  excepting  in  one  case.  I 
succeeded  in  relieving  it,  after  several  agents  had  failed,  by  the  admin- 
istration of  Sulphate  of  Atropia,  hypodermically,  the  one-hundredth 
of  a  grain  once  a  day,  until  relieved.  In  cases  of  acidity,  Lime-water 
may  be  used  with  some  advantage.  The  secretion,  when  profuse,  may 
be  moderated,  by  constantly  holding  in  the  mouth  some  candied  Sugar, 
or  a  lump  of  Gum  Arabic. 


DISEASES    OF    THE    PREGNANT    FEMALE.  217 

Anorexia,  or  a  want  of  appetite,  and  a  dislike  for  ordinary  aliments,, 
are  symptoms  frequently  met  with  at  various  stages  of  utero-gestation. 
These  may  be  owing  to  the  sympathetic  actions  existing  between  the 
uterus  and  digestive  organs,  to  a  torpid  state  of  the  organs  subser- 
vient to  digestion,  or  to  an  unloaded  condition  of  the  alimentary  canal. 
Usually,  puerperal  anorexia  requires  but  little  attention ;  but  where 
treatment  is  required,  it  must  be  based  upon  the  supposed  cause  of 
it — thus,  if  it  be  suspected  as  a  result  of  nervous  sympathy,  Pulsatiila 
or  Macrotys  will  generally  remove  it;  if  it  originates  from  torpor  of 
the  digestive  apparatus,  Nux  Vomica,  or  the  compound  tonic  mixture 
will  be  found  useful ;  and  if  it  be  induced  by  plethora,  or  an  accumu- 
lation of  morbid  matter  in  the  alimentary  canal,  Ignatia  may  be  used 
or  the  first  decimal  trituration  of  Podophyllin,  in  two  or  three  grain 
doses;  or  if  persistent,  mild  purgatives  will  be  essential.  Indeed, 
I  would  remark  here,  that  throughout  the  whole  period  of  utero- 
gestation,  if  the  bowels  be  kept  in  a  soluble  condition  by  mild 
aperients,  or  by  the  use  of  proper  food,  many  of  the  distressing 
symptoms  common  to  this  period  will  be  avoided.  Flatulence  may 
be  removed  by  the  use  of  Sp.  Tr.  Viburnum,  or  by  compound  spirits 
of  Lavender  given  in  some  sweetened  water.  To  overcome  these 
difficulties,  some  authors  recommend  emetics,  but  I  am  decidedly  op- 
posed to  their  use :  firstly,  because  milder  measures  will  accomplish 
all  that  can  be  desired ;  and  secondly,  because  emetics  have  a  tendency 
to  produce  abortion,  and  which  may  be  avoided  by  other  efficient  and 
less  hazardous  means.  There  are  some  practitioners  who  proceed, 
apparently,  as  if  they  supposed  every  patient's  stomach  to  be  a  strong 
metallic  vessel,  capable  of  being  acted  upon  by  emetics,  powerful  stim- 
ulants, drastic  purgatives,  etc.,  etc.,  without  the  least  injury  whatever, 
but  always  with  benefit ;  such  physicians,  of  all  men,  are  the  least 
adapted  to  obstetric  practice,  and  I  might  add  truly,  or  any  other. 

Either  with  or  without  anorexia,  the  patient  may  have  "  longings," 
or  a  desire  for  certain  articles,  which  are  sometimes  unnatural  and  even 
disgusting.  When  these  longings  are  not  directed  to  unwholesome  or 
dangerous  articles,  there  is  no  reason  why  they  should  not  be  indulged  ; 
neither  is  there  any  necessity  for  interfering  with  any  particular  dis- 
likes which  may  have  been  produced  in  the  patient's  mind.  In  rela- 
tion to  these  longings,  and  their  influence  upon  the  fetus  in  utero, 
when  ungratified,  as  well  as  to  the  effects  of  the  maternal  mind,  gen- 
erally, upon  it,  there  is  much  discordance  of  opinion  among  medical 
men,  some  believing  that  the  embryo  is  acted  upon  by  strong  mental 


218  KING'S  ECLECTIC  OBSTETRICS. 

emotions  of  the  mother,  .while  others  deride  the  idea.  I  must  confess, 
that  too  much  evidence,  of  a  direct  and  satisfactory  character,  has  been 
at  various  times  presented  to  me,  to  permit  me  for  a  moment  to  doubt 
this  point;  and  I  am  thoroughly  convinced,  that  the  fetus  in  utero  is 
subject  to  influences  and  changes,  resulting  entirely  from  the  mind  of 
its  mother,  when  under  strong  or  continuous  action.  How,  or  why 
this  is  produced,  is  as  difficult  for  me  to  explain,  as  it  would  be  to 
account  for  the  cessation  of  a  severe  labor-pain  on  the  entrance  of 
the  accoucheur  into  the  puerperal  room,  or  the  sudden  dissipation  of 
toothache  upon  obtaining  a  sight  of  the  forceps,  or  to  explain  why  one 
man  should  be  actively  purged  upon  seeing  another  swallow  a  nauseous 
dose  of  medicine.  I  know,  "  sympathy,"  and  "  imagination  "  are  held 
up  as  replies — but  if  these  are  applicable  to  the  latter  cases,  why  not 
to  the  former?  A  greater  attention  to  the  efforts  of  nature,  as  wit- 
nessed in  the  human  system,  and  less  attention  to  speculative  hypoth- 
esis and  dogmatic  authority,  wrould  tend  much  to  advance  the  true 
science  of  medicine.  He  who  really  desires  a  knowledge  of  the  truth, 
will  not  hesitate  to  receive  it  from  any  source. 

There  is  no  direct  vascular  communication  between  the  mother  and 
the  fetus,  nor  have  physiologists  been  able  to  detect  any  nervous  con- 
nection between  them,  and,  for  this  reason,  some  have  denied  the 
mental  influence  of  the  mother  upon  the  fetus  in  utero,  and  consider 
the  supposed  effects  of  this  influence  as  mere  coincidences,  and  not 
proofs.  And  yet,  it  appears  to  me,  these  coincidences,  as  they  are 
termed,  have  been  too  numerous,  and  often  too  prominently  marked, 
to  admit  of  any  doubt.  It  certainly  appears  to  have  been  believed, 
acted  upon,  and  with  successful  results,  in  ancient  times  (Genesis, 
chapter  xxx,  verses  30  to  41).  It  has  heretofore  been  referred  to, 
that,  notwithstanding  the  absence  of  direct  vascular  communication, 
the  fetus  has  been  acted  upon  by  medicine  taken  by  the  mother. 
Nerves  or  their  congeners  appear  to  be  necessary  to  animal  life  and 
development,  and  yet  how  many  most  perfectly  and  astonishingly 
made  living  creatures  are  there  in  whom  not  a  trace  of  nerve-tissue 
has  been  discovered ! 

Diarrhea  may  occur,  and  usually  yields  to  the  ordinary  treatment 
for  this  disease  when  independent  of  pregnancy.  It  may  be  owing  to 
intestinal  irritation,  which  may  be  the  result  of  constipation  preceding 
pregnancy,  or  it  may  be  induced  by  the  sympathy  existing  between 
the  intestines  and  the  excited  uterus;  under  either  of  these  circum- 


DISEASES    OF    THE    PREGNANT    FEMALE.  219 

stances,  the  early  administration  of  Aconite  and  Ipecac,  in  the  usual 
small  dose,  will,  a.s  a  rule,  give  prompt  relief.  Epilobium  is  Prof. 
Scudder's  remedy.  In  some  instances,  the  small  dose  of  the  first  dec- 
imal trituration  of  Podophyllin  will  be  the  remedy ;  the  base  of  the 
tongue  showing  a  dirty  coat  is  the  indication.  And  again,  I  have 
found  Sulphate  of  Quinia  with  essence  of  Cinnamon  to  be  decidedly 
beneficial.  "When  the  diarrhea  depends  upon  chronic  inflammation  of 
the  mucous  membrane  of  the  intestines,  it  becomes  of  a  serious  char- 
acter, and  unless  treated  promptly  and  properly,  may  terminate  fatally. 
In  this  case,  Euphorbia,  given  in  doses  of  from  one  to  ten  drops,  will 
relieve  the  irritation  and  promote  functional  activity  —  hot  fomenta- 
tions should  be  applied  over  the  abdomen,  and  mustard  to  the  dorsal 
and  lumbar  portions  of  the  vertebral  column.  The  soluble  Citrate  of 
Bismuth  (Liquor  Bismuth)  is  a  very  good  agent  in  overcoming  diar- 
rhea; one  grain  to  a  dram  of  water  is  the  dose.  In  addition  to  these, 
the  ordinary  treatment  for  inflammation  of  a  similar  character  must  be 
pursued,  meeting  the  symptoms  as  they  present  themselves.  Much 
benefit  will  be  derived  in  these  cases  by  the  alternate  use  of  tincture 
of  Aconite,  and  tincture  of  Ipecacuanha,  in  small  doses,  and  in  most 
cases  no  other  treatment  will  be  called  for.  The  diet  should  be  light, 
and  small  in  quantity,  consisting  principally  of  boiled  Milk,  boiled 
Rice,  Arrowroot,  etc.  Diarrhea  more  often  occasions  abortion  than 
does  constipation,  in  consequence  of  tenesmus,  and  which  usually 
occurs  about  the  third  month.  As  with  all  other  affections  during 
pregnancy,  care  must  be  taken  to  avoid  active  or  powerful  catharsis, 
whatever  may  be  the  agents  employed  in  their  treatment. 

Heartburn,  or  cardialgia,  is  a  distressing  symptom,  and  may  be  pres- 
ent during  the  early  period  of  conception,  not  until  the  third  or  fourth 
month,  or  may  be  entirely  absent.  It  may  be  occasioned  by  sym- 
pathetic action,  by  the  use  of  certain  articles  of  diet,  and  .by  the  pres- 
ence of  bile  in  the  stomach,  but  most  generally  it  arises  from  acidity 
of  the  stomach ;  it  is  also  said  to  be  caused  by  emotions  of  the  mind, 
and  an  affection  of  the  eighth  pair  of  nerves.  There  is  heat  or  a  burn- 
ing sensation  in  the  epigastric  region,  which  extends  upward  along 
the  esophagus,  with  pyrosis  or  eructations  of  a  clear,  bilious,  sour  and 
bitter  fluid,  and  is  frequently  accompanied  with  a  peculiar  sensation  of 
dragging  from  the  stomach  toward  the  spine ;  eating  aggravates  the 
difficulty.  There  is  generally  no  febrile  or  other  constitutional  dis- 
turbance present ;  the  appetite  is  commonly  impaired.  This  symptom 


220  KINO'S    ECLECTIC    OBSTETRICS. 

may  usually  be  mitigated  by  an  attention  to  the  bowels,  removing 
acidity  1  y  alkalies  in  aromatic  infusion,  by  a  rigid  attention  to  diet, 
which  should  be  light,  nourishing,  and  easy  of  digestion,  and  by  the 
use  of  moderate  exercise  in  the  open  air.  In  very  painful  and  obsti- 
nate cases,  counter-irritation,  as  sinapisms,  etc.,  applied  to  the  epi- 
o-astrium  will  be  productive  of  benefit.  A  long-continued  use  of 
alkalies  will  injure  the  tone  of  the  stomach.  Sometimes  alkalies  will 
fail  to  produce  the  slightest  relief;  in  such  cases  a  resort  to  acids  will 
often  effect  the  desired  result;  solution  of  Citric  acid,  Tartaric  acid, 
or  Lemon-juice  may  be  used,  or  elixir  of  Aritriol.  As  soon  as  some 
relief  has  been  afforded,  an  attempt  may  be  made  to  invigorate  the 
powers  of  the  stomach,  for  which  purpose  I  have  met  with  much 
benefit  from  very  small  doses  of  Pulv.  Hydrastis  Can.  and  Capsicum, 
administered  three  times  a  day,  near  meal  times.  Nux  Vomica  and 
Ipecac  are  good  agents  to  tone  the  stomach.  Generally  females  obtain 
a  temporary  relief  from  this  symptom,  when  not  obstinately  severe,  by 
taking  Lime-water,  or  chewing  Magnesia,.  Chalk,  or  Peach-kernels. 

Gastrodynia,  spasm  or  cramp  of  the  stomach,  is  frequently  the 
result  of  some  error  in  diet,  but  may  also  be  occasioned  by  cold  or 
violent  mental  emotions.  Its  attacks  are  often  sudden,  more  transient 
than  heartburn,  but  far  more  severe.  Violent  pains  of  a  neuralgic 
character  dart  from  the  sternum  through  to  the  back  or  shoulders,  being 
accompanied  with  great  distension,  flatulence,  restlessness  and  anxiety  ; 
it  may  be  so  severe  as  to  occasion  premature  labor,  or  the  death  of  the 
fetus.  The  treatment  should  be  prompt  and  energetic;  warm  fomen- 
tations, or  sinapisms,  should  be  applied  to  the  epigastrium.  Colocynth 
is  a  good  agent  where  the  pain  is  severe,  or  Viburnum  where  cramps 
are  present.  In  some  instances  of  a  severe  and  obstinate  character,  I 
have  succeeded  in  giving  relief  with  the  compound  tincture  of  Lobelia 
and  Capsicum,  also  with  the  tincture  of  Gelsernium.  When  the  attacks 
are  frequent,  they  may  be  overcome  by  keeping  the  bowels  regular, 
neutralizing  acidity  of  the  stomach,  and  administering  small  doses  of 
Nux  Vomica  several  times  a  day.  The  diet  should  be  light  and 
nutritious,  avoiding  fats,  acids,  and  stimulants.  Alkalies,  aromatics, 
and  anti-spasmodics,  are  the  only  internal  remedial  agents  generally 
required. 

Constipation  is  a  common  attendant  of  pregnancy,  and  is  frequently 
very  obstinate  and  troublesome.  It  is  caused  by  the  compression  of 


DISEASES    OF    THE    PREGNANT    FEMALE.  221 

the  gradually-developed  uterus  upon  the  rectum,  which  diminishes  its 
diameter,  as  well  as  impairs  its  activity;  constipation  may  also  be 
owing  to  digestive  derangements,  improper  food,  sedentary  living,  and 
other  causes  calculated  to  lessen  the  energy  of  the  intestines.  Various 
symptoms  depend  upon  this  condition  of  the  bowels,  as  headache,  or 
a  sense  of  fullness  and  weight  in  the  head,  sleeplessness,  irritability, 
pains  in  the  abdomen,  bloody  mucous  discharges,  nausea,  and,  in  the 
latter  period  of  pregnancy,  false  pains.  Sometimes,  notwithstanding 
accumulation  of  fecal  matter  in  the  intestines,  there  will  be  small  dis- 
charges of  a  liquid  character.  Constipation  is  a  symptom  always  to 
be  dreaded  in  the  pregnant  female,  because  of  its  liability  to  produce 
abortion  from  the  large  amount  of  feces  collected  in  the  rectum, 
requiring  great  expulsive  effort  to  remove,  as  well  as  its  tendency,  at 
the  time  of  parturition,  to  cause  protracted  labor,  peritonitis,  or  con- 
vulsions. Piles  are  usually  a  consequence  of  constipation  in  the  preg- 
nant female.  In  the  treatment  of  costiveness  during  pregnancy, 
especially  when  dependent  upon  impaction  of  the  lower  bowel,  or 
pressure  of  the  growing  uterus,  I  prefer  the  use  of  warm  laxative 
enemas  to  active  purgatives  administered  by  the  mouth,  and  for  this 
purpose  an  emulsion  of  Castor  Oil,  may  be  used  daily,  and  after  the 
rectal  accumulation  has  been  removed,  a  daily  enema  of  warm  water 
may  be  substituted  for  the  previous  one.  If  it  be  possible,  it  is 
always  decidedly  better  to  overcome  constipation  by  hygienic  than  by 
therapeutical  measures,  which  always  occasion  more  or  less  debility, 
or  else  some  digestive  derangement.  If  medicine  is  required,  and  the 
tongue  is  broad  and  pallid,  with  a  white  coating,  indicating  an  alkali, 
I  prefer  small  doses  of  Bicarbonate  of  Potassa  or  Soda,  to  any  other 
agent  with  which  I  am  acquainted.  Tincture  of  Nux  Voniica,  given 
alternately  with  Tincture  of  Belladonna,  or  Pulsatilla,  in  very  small 
doses,  has  proved  serviceable  in  cases  where  the  constipation  was  due 
to  lack  of  nervous  energy.  Podophyllin  is  often  called  for  in  these 
cases,  and  may  be  given,  either  in  the  form  of  the  small  pill  or  the 
trituration,  one  part  of  Podophyllin  to  one  hundred  parts  of  sugar  of 
milk.  Active  cathartics  are  seldom  required,  and  should  al\vays  be 
used  with  great  care  during  pregnancy,  on  account  of  their  tendency 
to  produce  premature  labor;  the  secret  of  success  consists  entirely  in 
maintaining  one  daily  alvine  evacuation.  I  have  recently  tested 
Glycerine  Suppositories,  with  very  satisfactory  results,  in  constipation; 
the  action  is  prompt,  and  the  effect  pleasant.  In  diarrhea,  the  prac- 
titioner should  always  ascertain  if  it  was  preceded  by  constipation, 


K  I  Mi's    ECLECTIC    OBSTETRK  -. 

and  should,  this  be  the  case,  laxative  measures  must  be  the  first 
adopted.  No  female  should  he  allowed  by  a,  physician  to  enter  the 
parturient  state  -with  constipated  bowels;  and  in  those  instances  where 
the  practitioner  attends  the  patient  previous  to  full  term,  he  is  highly 
reprehensible  if  he  neglects  the  proper  attention  to  this  condition. 
The  diet  in  these  cases  may  be  such  as  to  assist  very  much  in  bringing 
about  the  desired  regularity,  without  the  aid  of  physic,  as  brown 
bread,  mush  and  maple  syrup,  hasty  pudding,  oatmea'l,  figs,  stewed 
prunes,  dates,  ripe  fruits,  and  dried  laxative  fruits  stewed,  as  apples, 
peaches,  plums,  etc.  Any  irritability  of  the  bowels  which  may  follow 
a  removal  of  constipation  can  be  allayed  by  some  gentle  sedative,  as 
Aconite  and  Ipecac  or  Sp.  Tr.  of  Amygdalus  Per. 

Headache,  or  oephalcUgia,  is  of  very  common  occurrence  during 
pregnancy,  and  attacks  all  temperaments,  and  as  it  is  frequently  a 
premonitory  symptom  of  convulsions  or  mania,  the  practitioner  should 
not  fail  to  devote  especial  attention  to  its  removal.  The  pain  may  be 
constant  or  periodical,  acute  or  dull,  and  may  be  located  in  one  par- 
ticular part  of  the  head,  or  over  the  whole  of  it.  Sometimes,  espe- 
cially when  acute,  it  is  also  of  a  throbbing  character,  and  not  unfre- 
quently  there  is  an  intolerance  of  light  and  sound.  Usually  it  is 
owing  to  some  deranged  condition  of  the  digestive  organs,  and  may  be 
readily  removed  by  proper  attention  to  diet,  and  prescribing  such 
agents  as  are  specifically  indicated.  If  characterized  by  periodicity, 
Quinia,  or  Arsenicum,  i*  the  remedy.  If  pain  is  localized,  think  of 
Rhiis  Tox.  or  Bryonia,  and  if  the  pain  is  throbbing,  Belladonna.  It 
may,  likewise,  originate  from  mental  emotions,  fatigue,  stimulants, 
and  coitus,  requiring  special  sedatives,  and  quiet,  with  proper  hygi- 
enic measures;  if  anemia  exist,  some  preparation  of  iron  is  neces>ary. 
I  prefer  the  Acid  Solution  of  Iron,  and  suggest  its  use  in  this  condi- 
tion ;  if  albuminaria  be  present,  treat  as  herea'fter  directed.  The 
headache  which  occurs  during  the  early  months  of  utero-gestation  is 
of  a  nervous  character,  and  is  not  regarded  as  a  dangerous  symptom; 
while  that  which  occurs  during  the  latter  months  is  owing  to  plethora, 
is  usually  attended  by  evident  signs  of  cerebral  congestion,  and  must 
be  treated  promptly  and  energetically,  that  serious  results  may  not 
ensue.  This  latter  form,  unlike  the  former,  instead  of  being  relieved 
by  the  recumbent  position  is  more  or  less  aggravated  by  it,  and  is 
frequently  accompanied  with  a  quick,  full,  strong  pulse,  flushed 
countenance,  suffused  or  heavy  eyes,  heaviness  of  the  lids,  and  pho- 


DISEASES    OF    THE    PREGNANT    FEMALE.  223 

tobia;  the  carotids  pulsate  with  unusual  force  and  a  sensation  of 
giddiness  is  present,  which  is  increased  on  stooping.  Belladonna  is 
the  remedy  for  this  condition.  If  this  form  of  headache  is  permitted 
to  continue  without  relief  it  will  almost  assuredly  terminate  in  con- 
vulsions, more  especially  if  albuminous  urine  be  present. 

The  nervous  form  of  headache  may  be  removed,  as  before  observed, 
by  regulating  the  bowels,  and  attending  to  the  diet.  I  have  derived 
considerable  advantage  from  Rhus  Tox.,  Gelsemium,  Ammonia  Carb., 
and  Bryonia,  either  separately  or  in  such  combinations  as  indications 
direct,  and,  in  some  severe  instances,  counter-irritation  to  the  sub- 
occipital  region,  or  behind  the  ear.  This  annoying  symptom  may 
occasionally  prove  quite  persistent,  and  after  several  days  Pulsatilla 
may  become  the  indicated  remedy,  the  patient  showing  symptoms  of 
fear.  The  administration  of  this  agent  at  such  times,  will  promptly 
overcome  the  trouble. 

The  plethoric  variety  requires  somewhat  different  treatment;  the 
bowels  must  be  kept  entirely  free  from  any  disposition  to  constipation, 
counter-irritation  must  be  intermittingly  applied  to  the  whole  length 
of  the  spinal  column,  and  active  diuretics  may  be  safely  and  freely 
given.  Tincture  of  Nux  Vomica,  or  tincture  of  Belladonna,  in  small 
doses,  will  frequently  remove  the  headache.  If  the  urine  contains 
albumen,  the  means  hereafter  named  must -be  promptly  resorted  to. 
In  very  severe  cases  cupping  may  be  applied  to  the  temples,  or  nape 
of  the  neck.  Moderate  diaphoresis  will  likewise  be  found  serviceable, 
and  should  be  effected  by  the  use  of  the  simple  diaphoretics,  without 
the  administration  of  any  preparation  of  opium.  Although  local  de- 
pletion may  act  as  a  beneficial  palliatory  measure,  yet  general  bleeding, 
which  is  so  frequently  resorted  to  and  recommended  by  certain 
physicians  and  authors,  must  be  specially  guarded  against,  as  it  debil- 
itates the  female,  rendering  her  liable  to  premature  delivery,  tedious 
labor,  perhaps  requiring  instrumental  aid  or  hemorrhage  after  parturi- 
tion, and  frequently  tends  to  the  destruction  of  the  fetus. 

Convulsions  often  attend  the  condition  of  pregnancy;  their  most 
usual  periods  of  attack  are  in  the  latter  months,  during  parturition, 
or  shortly  after  delivery.  Those  convulsions  attended  with  or  pre- 
ceded by  signs  of  general  plethora,  and  cerebro-spinal  congestion,  and 
commonly  termed  "  puerperal  convulsions,"  will  be  treated  of  in  an- 
other part  of  the  work.  At  the  present  time,  I  would  call  attention 
to  a  form  of  convulsions,  which  I  have  met  with  as  early  as  at  the 


224  KIND'S     KC I.KIT  1C    OBSTETRICS. 

second  month  of  gestation,  and  which  occurs  much  more  frequently 
than  the  true  puerperal  convulsions.  They  most  generally  occur  in 
aiuemic  or  hysterical  patients,  or  in  those  whose  nervous  systems 
have  been  exhausted  by  any  depressing  cause,  and  though  when  the 
attacks  are  light  no  bad  results  follow,  yet  they  frequently  occasion 
premature  labor,  or,  by  appearing  at  the  parturient  period,  perplex, 
embarrass,  and,  perhaps,  alarm  the -practitioner.  They  are,  undoubt- 
edly, of  an  hysterical  character,  and  differ  from  the  true  puerperal 
convulsions,  in  being  often  preceded  or  attended  by  the  globus  hyster- 
icus  and  borborygmus,  with  a  small,  hard  -pulse  peculiar  to  ordinary 
hysterical  attacks;  the  motions  of  the  limbs  are  likewise  more  violent, 
the  eyes  roll  or  store  with  a  wild  expression,  and  though  they  may  be 
unnaturally  brilliant,  yet  there  will  be  no  suffusion,  and  the  pupil  is 
not  insensible.  Occasionally  the  ordinary  concomitants  of  sobbing, 
crying,  or  screaming  will  take  place.  Urine,  of  a  pale  color,  is  fre- 
quently voided  in  large  quantities.  In  the  treatment  of  this  form  of 
convulsion  the  greatest  reliance  was  formerly  placed  on  the  officinal 
compound  tincture  of  Lobelia  and  Capsicum  (Antispasmodic  tincture), 
in  doses  of  from  a  fluid  drachm  to  half  a  fluid  ounce,  and  repeated 
every  ten  or  twenty  minutes,  nntil  the  attack  was  overcome.  This 
compound  is  probably  one  of  our  most  powerful  antispasmodics ;  but 
owing  to  its  disagreeable  taste,  together  with  the  large  dose  required, 
it  is  not  so  generally  used  as  heretofore.  Gelsemium  is  now  used  quite 
extensively  in  these  cases,  and  in  small  doses  frequently  repeated  will 
prove  quite  efficient.  Bromide  of  Ammonium  is  also  a  good  agent, 
and  may  be  used  either  singly  or  in  combination  with  Gelsemium.  In 
obstinate  cases,  Chloroform  should  be  inhaled  by  the  patient  until 
spasmodic  action  is  overcome  and  complete  relaxation  produced.  In 
the  meantime,  dring  the  absence  of  these  convulsions,  the  patient  must 
be  placed  upon  a  generous  diet  of  an  easily  digestible  character ;  the 
bowels  must  be  kept  regular,  wine  or  ale  may  be  allowred,  with  some 
chalybeate  preparation,  the  use  of  which  should  be  continued  during 
the  whole  course  of  utero-gestation,  unless  otherwise  contra-indicated; 
all  exciting  influences  should  be  removed  as  much  as  possible,  quiet 
should  be  enjoined,  excessive  depletion  by  diaphoresis,  diuresis,  or 
catharsis  are  to  be  avoided,  and  coitus  must  be  absolutely  prohibited. 
In  these  instances,  I  commonly  leave  some  such  agents  as  above 
named  with  the  patient,  to  be  administered  by  her  friends  whenever 
an  attack  occurs,  and  which  effects  its  influence  without  the  necessity 
of  my  presence  on  every  occasion.  With  this  class  of  patients,  the 


DISEASES    OF    THE    PREGNANT    FEMALE.  225 

practitioner  should  always  be  prepared  to  meet  this  symptom  as  a 
complication  at  the  period  of  parturition,  for  it  not  uncommonly  hap- 
pens that  one  or  several  attacks  come  on  during  the  labor,  as  well  as 
subsequently.  Occurring  at  this  time,  Chloroform  should  be  promptly 
administered,  which  will  usually  immediately  overcome  all  convulsive 
action. 

When  there  is  a  tendency  to  epileptic  convulsions,  more  or  less 
giddiness  is  apt  to  be  present,  and  the  urine  will  always  be  found  to 
contain  a  little  albumen.  Again,  when  albumen  is  continuously  pres- 
ent in  the  urine  of  a  pregnant  woman,  there  is  always  danger  to  fear 
from  puerperal  convulsions,  and  more  especially  if  this  be  associated 
with  a  plethoric  condition.  It  is,  therefore,  the  positive  duty  of  every 
obstetrician  to  examine  the  urine  of  his  patients  from  time  to  time 
during  pregnancy,  and  especially  when  oedema  of  the  extremities  is 
present,  and  also  in  the  latter  months,  to  discover  whether  it  contains 
albumen,  as  well  as  a  diminished  quantity  of  urea,  and  thus  enable 
him  to  promptly  resort  to  measures  for  the  prevention  of  a  convulsive 
attack;  though  it  must  not  be  forgotten  that  puerperal  convulsions 
frequently  come  on  without  any  previous  albuminous  condition  of  the 
urine.  Headache,  dimness  of  vision,  giddiness,  are  apt  to  be  present, 
and,  sometimes  even  amaurosis,  when  albumen  exists;  and  this  con- 
dition is  often  accompanied  with  oedema  of  the  extremities  and  cellu- 
lar tissue  of  the  body,  and  appears  to  be  more  common  with  primipars& 
than  with  multiparse.  It  has  been  attributed  to  pressure  of  the  gravid 
uterus  upon  the  kidneys,  and  likewise,  with  much  greater  probability, 
to  sympathetic  irritation  of  these  organs.  There  is  no  doubt  that  not 
only  albuminaria,  but  often  even  true  kidney  disease,  follow  the  renal 
congestion  kept  up  by  the  pregnant  condition.  In  cases  of  albuminous 
urine  it  will  be  found  useful  to  produce  derivative  action  by  hot  or 
stimulating  local  applications,  dry  cupping  or  even  cupping  with  scari- 
fication over  the  loins  and  renal  region;  and  even  active  catharsis. 
We  should,  however,  be  extremely  careful  that  the  bowels  are  not  acted 
on  to  such  an  extent  as  to  produce  exhaustion,  or  that  an  irritation  of 
the  intestinal  mucous  membrane  is  not  excited  that  will  prevent  proper 
digestion.  The  Spirit-vapor  Bath  is  very  useful  in  all  cases.  The  in- 
ternal remedies  will  depend  entirely  upon  the  general  conditions  and 
surrounding  circumstances  of  the  patient;  we  would  think  of  Macro- 
tys,  Rhus  Tox,  Bryonia,  Gelsemium,  Eryngium,  or  Belladonna,  as  in- 
dicated. In  some  cases  we  find  the  urine  alkaline,  and  we  supply  the 
acids,  Nitric  acid  being  specially  indicated.  Again  there  are  cases  in 
15 


226  KING'S  ECLECTIC  OBSTETRICS. 

which  it  is  decidedly  acid,  and  Bicarbonate  of  Soda  becomes  the  indi- 
cated remedy.  Digitalis,  Tannin,  Bcn/.nic  acid,  Citric  acid,  Gallic 
acid,  etc.,  IKIVC  each,  been  found  advantageous  when  administered  un- 
der the  proper  circumstances.  When  there  is  a  deficient  oxygcui/ation 
of  the  blood,  Nitric  acid,  Nitrate  of  Ammonia,  Peroxide  of  Iron,  etc., 
are  indicated.  And  after  the  albumen  has  diminished,  with  an  in- 
crease of  urea  and  urine,  blood  restoratives  as,  the  Acid  Solution  of 
Iron,  Citrate,  Pyrophosphate,  or  Carbonate  of  Iron,  with  or  without 
Quin ia  or  other  tonics,  must  be  administered,  together  with  a  nutri- 
tious, digestible  diet. 

According  to  Andral  and  Gavarret,  the  fibrin  of  the  blood  is  dimin- 
ished during  the  first  six  months  of  pregnancy,  but  subsequently  be- 
comes augmented,  even  to  a  considerable  amount  above  the  usual 
physiological  portion,  assuming  the  characteristics  of  inflammatory 
blood,  and  manifesting  the  buffy  coat  after  venesection.  In  addition 
to  which,  the  quantity  of  the  blood  is  also  considerably  increased  be- 
yond the  usual  normal  proportion.  These  changes  in  the  blood  are, 
very  probably,  due  to  an  increased  nutrition,  by  which  chyle  is  formed 
in  greater  abundance  from  the  food,  and  conveyed  to  the  blood-vessels. 
This  plethoric  condition  is  a  natural  and  salutary  consequence  of  preg- 
nancy, and  under  ordinary  circumstances  requires  but  little  attention, 
further  than  active  exercise  and  moderate  diet.  But  occasionally  these 
additions  to  the  quantity  and  quality  of  the  blood  become  so  great  as  to 
develop  symptoms  demanding  prompt  therapeutic  treatment,  which  is 
more  especially  the  case  with  indolent  females,  those  who  live  luxuri- 
ously, and  those  of  sanguine  habit ;  it  may  also  be  induced  by  constipa- 
tion. These  symptoms  are  headache,  somnolence,  flushed  face,  vertigo, 
dyspnoea,  full  and  frequent  pulse,  heat  of  the  skin,  depressed  spirits,  and 
high-colored  urine.  Sometimes  the  general  plethora  gives  rise  to  local 
plethora,  which  may  be  followed  by  congestion  of  a  serious  character 
in  the  brain,  lungs,  or  uterus.  This  latter  organ,  during  pregnancy, 
is  the  most  liable  to  hyperasmia,  which  may  be  known  by  a  sensation 
of  fullness  and  weight  in  the  pelvis,  groins,  and  thighs,  tension  or 
swelling  of  the  abdomen,  pain  in  the  kidneys  or  loins  and  even  symp- 
toms of  premature  labor;  and,  not  unfrequently,  this  condition  of  the 
mother  exerts  an  influence  on  the  fetus,  in  consequence  of  which,  its 
movements  become  less  frequent  and  weaker,  or  perhaps"  cease  alto- 
gether, but  which,  if  not  allowed  to  proceed  too  far  before  giving  re- 
lief, will  again  appear  with  the  removal  of  the  local  plethora. 


DISEASES    OF    THE    PREGNANT    FEMALE.  227 

Whenever  the  symptoms  of  general  or  local  plethora  become  so 
severe  as  to  require  remedial  measures,  and  no  symptoms  of  approach- 
ing miscarriage  have  been  manifested,  it  will  frequently,  but  not  always, 
be  advisable  to  commence  the  treatment  with  a  cathartic,  followed  by 
diuretics,  which  will  be  found  to  exert  a  safer  and  more  salutary  de- 
pletory influence,  than  even  general  bleedings,  which  are  so  highly 
recommended  by  many  medical  writers.  Infusion  of  Digitalis,  Sp.  Tr. 
Apis  Mel.  Asclepias,  and  Gelscmiuin  will  be  found  quite  useful  agents 
in  diminishing  the  plethoric  condition.  The  hot  water  bath,  and  dry- 
ing with  a  rough  towel,  will  favor  general  depiction  by  stimulating 
the  action  of  the  skin.  Counter-irritation  by  dry  cupping,  sinapisms, 
or  other  means  should  be  applied  to  the  upper  portion  of  the  spine; 
the  legs  and  arms  may  be  rubbed  or  bathed  with  some  stimulating 
liquid,  and,  very  frequently  the  wet  sheet,  or  rather  bandage  applied 
around  the  abdomen  and  pelvic  region  will  effect  much  benefit;  if  the 
case  be  very  severe,  tending  to  a  miscarriage,  cupping  may  be  pursued, 
applying  the  cups  to  the  loins  and  over  the  sacrum.  On  no  account 
must  large  or  small  general  bleedings  be  had  [except  when  the  urine 
is  found  to  be  excessively  albuminous,  endangering  an  attack  of  con- 
vulsions, in  which  case  cupping  upon  the  loins  may  tend  to  preserve 
from  such  attack],  for  though  they  may  occasionally  be  followed  by 
present  relief,  yet  their  after  consequences  are  much  to  be  dreaded; 
beside  it  is  a  well-established  fact  at  this  day,  that  bleeding  rather  in- 
creases than  diminishes. the  tendency  to  an  inflammatory  condition  of 
the  blood.  After  the  symptoms  have  been  removed  by  the  above 
treatment,  the  subsequent  measures  should  be  light  diet,  moderate  ex- 
ercise,, regularity  of  the  bowels,  and  use  of  Macrotys,  or  the  Parturi- 
ent Balm,  which  will  be  found  a  most  excellent  agent  at  this  time, 
with  an  occasional  use  of  diuretics,  and  the  use  of  a  bandage  or  proper 
support  to  the  uterus,  if  necessary.  Hemorrhage,  or  symptoms  of 
miscarriage,  are  to  be  treated  as  laid  down  elsewhere  for  these  diffi- 
culties. 

I  should  observe  here,  that  local  congestion  of  the  uterus,  or  of  any 
other  organ  is  not  necessarily  connected  with  general  plethora,  but 
may  exist  with  a  state  of  general  anaemia;  under  which  circumstances, 
the  nervous  and  vascular  systems  will  be  found  in  an  extremely  ex- 
citable condition.  In  such  cases,  after  the  removal  of  the  local  hyper- 
sernia,  proper  attention  should  be  bestowed  upon  the  existing  anaemia. 

Odontalgia,  or  toothache  [facial  neuralgia],  is  frequently  a  trouble- 
some symptom  with  pregnant  women;  it  may  occur  with  or  without 


228  KINO'S  KCi.ECTtr  OP.STKTRICS. 

caries,  and  may  appear  at  any  period  of  utero-gestation,  often  contirv- 
uing  until  parturition;  the  pain  is  most  usually  intermittent,  but  is 
occasionally  continuous.  Generally,  it  is  owing  to  increased  irritabil- 
ity of- the  nervous  system,  and  at  times  to  a  sanguineous  congestion 
of  the  jaw.  As  the  extraction  of  a  tooth  during  pregnancy  is  fre- 
quently followed  by  premature  labor,  it  is  not  prudent  to  resort  to  this 
expedient,  even  should  caries  be  present;  and  it  seldom  happens  that 
any  alleviation  of  the  suffering  follows  the  operation.  However,  should 
the  pain  be  owing  to  a  carious  tooth,  the  patient  suffering  severely 
without  any  relief  being  afforded,  and  other  means  have  failed,  then 
the  tooth  may  be  extracted  by  a  skillful  dentist,  and  probably  the  ad- 
ministration of  Chloroform  would  entirely  prevent  any  bad  influence 
upon  the  generative  system  from  the  shock  of  the  operation.  The 
proper  treatment  in  these  cases  is  the  administration  of  Aconite,  Ver- 
atrum,  Rhus,  Macrotys,  or  Viburnum,  as  they  may  be  severally  indi- 
cated. Where  the  pains  occur  periodically,  Sulphate  of  Quinia  should 
be  given;  the  bowels  should  be  kept  in  a  regular  condition  by  gentle 
laxatives;  and  as  a  local  application,  washing  the  mouth  frequently 
with  cold  or  tepid  water  and  salt  will  be  found  useful.  In  very 
severe  and  obstinate  cases,  counter-irritation  behind  the  ears  will  be 
followed  by  excellent  results,  as  a  sinapism,  or  stimulating  liniments. 
Tinture  of  Aconite  root,  employed  in  friction  beneath  the  ear,  is  said 
to  be  a  very  effectual  remedy,  and  is  certainly  deserving  a  trial  in  this 
distressing  complaint.  Chloroform  applied  locally,  either  alone,  or  in 
combination  with  equal  parts  of  tinctures  of  Camphor,  Aconite  root, 
and  Opium,  has  likewise  proved  efficacious.  If  caries  be  present,  the 
cavity  should  be  cleansed,  and  the  following  mixture  applied  on  cot- 
ton or  lint,  and  frequently  repeated  until  relief  is  obtained,  viz.:  Take 
of  Oils  of  Cajeput,  Cloves,  and  Amber,  each  one  fluid  drachm,  Camphor 
one  drachm,  rub  the  Camphor  with  the  oils  until  it  is  dissolved.  Or, 
Chloroform  may  be  applied  similarly.  In  the  toothache  of  pregnancy, 
the  breath  is  very  apt  to  be  acid,  and  will  redden  litmus ;  frequently, 
when  constipation  is  a  concomitant,  its  removal  will  be  followed  by  a 
cessation  of  the  pain. 

It  is  frequently  the  case  that  the  nervous  excitement  produced  in 
the  uterus  by  the  condition  of  pregnancy  extends  to  the  kidneys  and 
ureters,  giving  rise  to  spasmodic  action  of  the  ureters,  attended  with 
severe  pain  along  their  course,  and  occasionally  strangury,  and  which, 
if  not  promptly  relieved,  may  induce  premature  labor.  In  these  in- 


DISEASES    OF    THE    PREGNANT    FEMALE.  229 

stances  counter-irritation  should  be  applied  over  the  lumbar  region, 
and  sedatives  administered  internally.  The  tincture  of  Gclsemium 
alone,  or  combined  with  the  tincture  of  Macrotys,  will  prove  a  very 
useful  remedy.  Where  strangury  is  present,  Gelsemium  and  Lobelia 
will  prove  valuable  agents  as  relaxants.  The  inhalation  of  Chloro- 
form may  be  necessary  in  some  cases.  The  hot  hip-bath  will  be  found 
a  soothing  means  of  relief  in  this  complication.  Constipation  is  usu- 
ally present,  and  may  be  overcome  by  copious  warm  enemata. 

The  bladder  may  likewise  become  the  seat  of  sympathetic  nervous 
excitement,  especially  the  urethra  and  neck,  giving  rise  to  a  constant 
sensation  or  desire  of  urinating,  and  the  urine  passes  in  small  quanti- 
ties, frequently  with  pain  and  difficulty,  and  is  likewise,  with  some 
patients,  attended  with  excessive  irritability  of  the  external  genera- 
tive organs,  and  more  or  less  severe  and  distressing  itching,  which  is 
increased  at  night.  The  internal  use  of  Aconite,  Gelsemium,  Rhus, 
Apis  and  Eryngium  are  the  remedies  usually  indicated ;  hot  applica- 
tions over  the  region  of  the  bladder  may  also  be  used  as  an  additional 
means  of  relief;  sometimes,  liquor  Potassa  may  be  advantageously  ad- 
ministered with  other  means.  The  bowels  should  be  kept  regular, 
and  the  diet  should  be  of  a  mild,  not  stimulating,  character.  In  all 
troublesome  or  obstinate  cases  the  urine  should  be  examined,  and  if 
an  excess  of"  uric  acid,  urea,  or  phosphates,  etc.,  be  discovered,  the 
proper  treatment  therefor  must  be  pursued.  For  the  itching  of  the 
genitals,  cold  applications  should  be  employed,  and  the  parts  kept  well 
cleansed.  (See  Pruritus  of  the  Vulva.} 

Occasionally,  from  pressure,  or  perhaps  from  an  increased  deter- 
mination of  blood  to  the  uterus,  which  withdraws  this  fluid  from  the 
immediate  neighboring  parts,  there  wrill  be  found  a  torpor  of  the  blad- 
der, giving  rise  to  a  retention  of  urine  and  its  difficult  passage.  This 
is  a  more  serious  difficulty  than  the  previous  one,  on  account  of  its 
tendency  to  produce  retroversion  of  the  uterus.  Eupatorium  Pur  will 
favor  an  increased  flow  of  urine ;  Apis  in  some  cases  Mall  prove  effect- 
ual. Santonin,  in  two  or  three  grain  doses,  exerts  a  specific  action,  by 
stimulating  contractions  of  the  bladder.  Acetate  of  Potassa  should 
also  be  thought  of;  the  patient  should  be  advised  to  empty  the  blad- 
der often,  if  possible,  by  her  own  efforts,  and  should  these  means  fail, 
the  urine  must  be  removed  by  the  careful  introduction  of  a  catheter; 
wrhich  operation  must  not  be  delayed  for  too  long  a  period. 


230  KINc's    K<  I.K<  TIC    OBSTETRICS. 


Syncope,  or  Jit*  o/'/i'mf//^  frequently  attend  the  pregnant  condition, 
and  may  occur  at  any  period  from  conception  to  parturition,  though 
more  commonly  during  the  earlier  months;  vertigo,  or  dimness  of 
sight,  is  also  apt  to  be  present,  with  sometimes  tinnitus,  and  weakness 
of  the  knees.  These  affections  may  be  owing  to  debility  from  what- 
ever cause,  to  extreme  nervous  susceptibility,  or  to  plethora.  Syncope 
generally  occurs  while  the  patient  is  standing,  is  seldom  of  long  dura- 
tion, and  very  seldom  causes  any  serious  results.  However,  when 
frequently  repeated  it  may  induce  premature  labor,  which  should  be 
carefully  guarded  against.  The  treatment  should  be  that  usually  pur- 
sued in  syncope  at  other  times;  put  the  patient  in  a  recumbent  posi- 
tion, in  a  place  where  there  is  a  circulation  of  cool  air  —  dash  cold 
water  on  the  face  —  apply  Ammonia,  Ether,  or  Vinegar,  etc.,  to  the 
nose,  and  after  her  recovery,  should  there  be  much  debility,  with  cool- 
ness of  the  surface,  diffusible  stimuli  may  be  administered  internally, 
with  frictions  to  the  limbs,  and,  in  severe  cases,  along  the  spinal  col- 
umn. When  the  attacks  are  severe,  and  occur  frequently,  Pulsatilla, 
Gelsemium,  Digitalis,  and  in  some  cases,  Bromide  of  Ammonium  may 
be  given  with  benefit.  The  food  should  be  wholesome,  and  restricted 
somewhat  as  to  quantity,  and  if  the  patient  be  weak,  tonics  may  also 
be  employed.  When  these  attacks  are  frequent,  Sulphate  of  Quinia, 
or  Strychnia  will  be  efficacious  ;  if  anemia  be  present,  the  Acid  Solu- 
tion of  Iron. 

Palpitation  of  the  heart  is  not  an  unusual  occurrence,  during  preg- 
nancy ;  it  is  a  distressing  symptom,  and  though  by  no  means  danger- 
ous, it  occasions  i  much  alarm  to  the  patient.  It  may  happen  at  any 
period  of  utero-gestation,  and  may  be  owing  to  mental  excitement, 
derangement  of  the  digestive  organs,  pressure,  flatulency,  or  sympa- 
thetic nervous  irritation.  During  its  presence,  it  may  be  relieved  by 
the  administration  of  an  alkali,  if  acidity  and  flatulency  are  present; 
by  a  mild  laxative  if  the  bowels  are  confined  ;  and  under  other  cir- 
cumstances, Digitalis,  Lobelia,  Cactus,  Strophanthus,  and  in  some  cases 
stimulants  may  be  employed,  according  to  indications.  Four  to  eight 
drops  of  the  Sp.  Tr.  of  Digitalis,  given  daily  for  some  time  after  a 
paroxysm  subsides,  may  prevent  a  return  of  the  same.  During  the 
interval,  some  of  the  bitter  tonics  may  be  administered,  and  will  often 
be  found  beneficial  in  preventing  a  return  of  the  palpitation,  and 
should  the  patient  be  of  an  anaemic  habit,  the  proper  chalybeate^ 
must  be  used  in  conjunction.  The  diet  must  be  mild  and  stimulating,. 


DISEASES    OF    THE    PREGNANT    FEMALE.  231 

the  patient  should  exercise  moderately,  her  dress  should  be  loose, 
coitus  should  be  abstained  from  entirely,  and  the  mind  should  be  kept 
perfectly  tranquil. 

Dyspnoea,  or  difficulty  of  breathing,  may  occur,  in  the  early  months, 
from  sympathy,  and  at  a  later  period  from  plethora,  or  from  pressure 
of  the  enlarged  uterus;  it  may  likewise  be  owing  to  derangement  of 
the  digestive  organs,  thoracic  disease,  cardiac  disease,  tumors,  etc.  The 
treatment  will  consist  in  the  administration  of  antispasmodics,  as  Gel- 
semium,  Lobelia,  Ether  Carbonate  of  Ammonia,  etc.,  attention  to  the 
regularity  of  the  bowels,  and  a  course  similar  to  that  just  named  for 
palpitation.  When  owing  to  organic  diseases,  or  congestion  of  the 
lungs,  these  must  be  attended  to  according  to  their  indications.  When 
the  difficulty  is  owing  to  the  enlargement  of  the  uterus,  but  little  relief 
can  be  expected  until  the  delivery  of  the  fetus,  hence,  there  will  be  no 
necessity  for  injuring  the  patient's  system  by  the  employment  of 
medicines. 

Cough  sometimes  occurs,  independent  of  cold  or  existing  disease, 
and  which,  in  the  earlier  months,  is  owing  to  sympathetic  action ;  in 
the  latter  to  pressure.  The  cough  is  usually  short,  dry,  hacking,  and 
constant ;  occasionally  very  severe,  with  but  little  or  no  expectoration, 
no  febrile  symptoms,  and  no  change  in  the  pulse,  and  is  apt  to  cause 
premature  delivery.  It  may  be  treated  by  narcotics,  antispasmodics, 
rest,  and  regularity  of  the  bowels,  with  a  proper  attention  to  diet. 

In  the  latter  months  of  pregnancy,  when  the  cough  is  severe  and 
persistent,  Belladonna,  Pulsatilla,  Sanguinaria,  and  occasionally  an 
anodyne  may  be  employed..  Drosera,  Bromide  of  Potassium,  Trifolium, 
Bromide  of  Ammonia,  etc.,  are  advised  by  Prof.  J.  M.  Scudder.  If 
the  cough  be  due  to  irritation  of  the  diaphragm  and  lungs  from  upward 
pressure  of  the  enlarged  uterus,  but  little  can  be  done,  except  to  keep 
the  bowel?  regular,  the  urinary  organs  healthy,  and  during  sleep  to 
have  the  head  kept  in  a  somewhat  elevated  position.  The  cough  will 
pass  away  after  parturition. 

Mastodynia,  or  a  painful  and  distended  condition  of  the  breasts,  is 
very  apt  to  attend  pregnancy,  especially  with  prirniparaB,  and  may  be 
owing  to  the  rapid  development  of  these  organs  and  flow  of  blood  to 
them.  When  severe,  relief  is  frequently  afforded  naturally  by  a  thin, 
colorless,  serous  discharge  from  the  nipple.  To  relieve  congestion, 


232  KIND'S   KCLKCTIC 

aiul  prevent  inflammation,  which  are  the  principal  indications,  topid 
fomentations  may  be  applied,  together  with  an  anodyne  liniment,  as  a 
mixture  of  Oil  and  Laudanum;  the  bowels  must  be  kept  free,  and  all 
pressure  upon  the  breasts  removed.  The  Sp.  Tr.  of  Phytolacca  Dec. 
will  be  found  exceedingly  useful  in  these  cases,  in  doses  of  one  to  two 
minims,  administered  in  some  water,  and  repeated  every  three  or  four 
hours,  at  the  same  time  applying  it  locally.  Tincture  of  Iri.s  Versi- 
color  will  also  prove  beneficial  in  many  instances. 


pain  about  the  pelvis  and  hips,  as  well  as  the  abdomen, 
frequently  accompany  pregnancy;  the  cause  of  these  pains  is  supposed 
to  be  owing  to  pressure  on  the  anterior  branches  of  the  sacral  nerves  ; 
but  this  could  only  happen  when  there  has  been  a  descent  of  the  uterus, 
at  the  termination  of  utero-gestation,  for  prior  to  this  period  the  uterus 
is  too  much  elevated  for  its  inferior  portion  to  compress  these  nerve-. 
As  these  pains  are  more  common  after  fatigue,  they  are  probably  de- 
pendent on  an  irritable  condition  of  the  nerves  of  the  painful  muscles, 
and  should  be  treated  principally  by  rest.  In  severe  cases  Macrotys 
may  be  given  internally,  and  stimulating  liniments  may  be  rubbed 
over  the  affected  parts,  and  the  back;  and  the  pain  of  the  abdominal 
muscles  may  be  frequently  relieved  by  the  use  of  a  bandage. 

Mania,  or  insanity,  usually  attacks  pregnant  females  of  a  hysterical 
disposition,  or  those  who  are  hereditarily  predisposed  to  it.  It  may 
occur  at  any  period  of  utero-gestation,  from  conception  to  parturition, 
and  as  a  general  rule,  is  not  so  severe  as  that  which  occurs  in  the 
puerperal  state,  and  ceases  with  delivery.  The  treatment  must  be 
principally  moral,  meeting  any  symptoms  which  present  themselves, 
according  to  their  indications;  employing  tonic  means,  where  debility 
is  present;  Pulsatilla,  Macrotys,  Stramonium,  and  the  Bromides,  as 
they  may  be  specifically  indicated,  where  there  is  much  nervous  irri- 
tability; and  the  means  recommended  for  plethora,  or  albuminous 
urine,  should  these  exist.  The  application  of  cold  to  the  head,  stimu- 
lants to  the  spine,  and  cups  to  the  temples  or  back  of  the  neck,  should 
always  be  employed,  as  may  be  indicated,  to  overcome  any  local  con- 
gestion. When  the  mania  is  acute,  treat  it  in  the  manner  recom- 
mended for  Puerperal  Mania,  which  see. 

Beside  the  several  affections  which  have  just  been  named,  as  owing 
to  nervous  sympathy  and  deranged  circulation,  there  will  be  found 


DISEASES    OF    THE    PTIPXiXANT    FEMALE.  233 

certain  changes  in  the  mental  condition  of  the  patient;  thus  .she  may 
become  very  despondent,  or  very  irritable.  The  former,  when  severe 
and  obstinate,  and  accompanied  with  gradual  loss  of  health,  may 
terminate  eventually  in  puerperal  mania ;  the  latter  has  nothing  serious 
in  its  tendency,  and  disappears  after  delivery.  The  first  must  be  treated 
by  moral  as  well  as  therapeutical  means;  the  patient  should  be  kept 
from  all  depressing  circumstances,  should  be  led  into  cheerful  society, 
where  she  will  not  hear  of  any  wonderful  or  fatal  accidents  having 
occurred  to  parturient  women,  and  should  be  exhorted  to  overcome 
the  tendency  to  despondency  as  much  as  possible ;  the  therapeutical 
measures  should  be  Pulsatilla,  Viburnum,  the  Compound  Tonic  Mix- 
ture, cold  to  the  head,  diuretics,  etc.,  if  plethora  exist;  and  chalybeate 
tonics  when  an  anaemic  condition  is  present. 

The  second  should  be  treated  by  the  use  of  Macrotys,  keeping  the 
bowels  regular,  and  should  wakefulness  be  present,  the  following  may 
be  administered,  Sp.  Tr.  of  Aconite,  Sp.  Tr.  of  Hyoscyamus,  Sp.  Tr. 
of  Gelscmium,  etc.,  as  indications  direct.  The  patient  should  take 
moderate,  but  regular  exercise  daily  in  the  open  air,  and  the  diet 
should  be  of  a  non-stimulant  and  non-heating  character. 

Pruritus  of  the  Vulca,  Prurigo,  or  itching  of  the  Genitals,  occurs 
during  the  early  months  of  pregnancy,  and  is  sometimes  very  distress- 
ing; occasionally  it  continues  during  the  whole  period  of  utero-gesta- 
tion,  and  disappears  immediately  after  delivery.  It  may  be  caused  by 
uncleanliness,  acrid  discharges,  and  frequently,  according  to  Dewees, 
from  aphthous  efflorescence  of  the  vulva ;  at  times,  it  occurs  without 
any  known  cause.  In  the  treatment  of  this  distressing  symptom, 
means  must  be  employed  according  to  its  severity,  and  the  pathologi- 
cal condition  of  the  parts  affected.  In  the  greater  number  of  cases 
a  solution  of  Borax  will  be  found  efficient;  if  much  inflammation  of 
the  parts  is  present,  a  wreak  solution  of  the  Sesquicarbonate  of  Potassa, 
or  of  Nitrate  of  Silver  may  be  applied  locally,  and  as  it  subsides  an 
astringent  infusion  may  be  substituted,  as  of  Geranium  and  Golden 
Seal ;  a  compress  of  lint  or  soft  linen  should  be  moistened  with  these 
applications,  and  placed  between  the  labia  immediately  in  contact 
with  the  affected  parts.  A  very  excellent  preparation  is  composed  of 
Carbolic  acid  five  grains,  Acetate  of  Morphia  four  grains,  Dilute  Hy- 
drocyanic acid  one  fluid  drachm,  Glycerin  two  fluid  drachms,  distilled 
Water  a  sufficient  quantity  to  make  two  fluid  ounces  of  the  mixture; 
moisten  some  lint  with  this,  and  apply  it  upon  the  part  affected.  In 


234  KING'S  ECLECTIC  ORSTETRICS. 

all  cases  the  bowels  should  be  kept  regular,  and  the  parts  well  cleansed. 
Occasional  tepid  baths  may  be  employed  with  benefit,  and  sometimes 
the  induction  of  diaphoresis  will  produce  a  favorable  result.  Inter- 
nally, but  little  means  are  required;  Rims  Tox,  Apis,  or  Eryngium 
may  be  administered,  if  such  agents  are  desired.  If  the  pruritus  pre- 
sents characters  pf  periodicity,  Sulphate  of  Quinine,  Macrotys,  or 
Arsenicum,  etc.,  may  be  administered,  according  to  the  indications 
present.  The  Juniper  Pomade  applied  on  lint,  I  have  found  highly 
successful  in  a  number  of  cases;  and  in  others,  the  disease  has  disap- 
peared as  if  by  magic,  upon  the  local  application  of  a  lotion  composed 
of  a  saturated  aqueous  solution  of  Sulphurous  Acid  Gas  one  fluid 
ounce,  and  rain-water  three  fluid  ounces.  The  saturated  solution  may 
be  made  by  passing  a  stream  of  the  gas  through  water,  until  this  is 
saturated.  Wet  a  piece  of  lint  or  linen  with  it  and  apply  to  the  part. 
One  part  of  Carbolic  acid  to  fifty  or  sixty  parts  of  water  may  fre- 
quently be  locally  applied  with  advantage.  If  the  itching  be  due  to 
pediculi,  Cologne,  or  the  above  carbolic  preparations,  will  remove 
them  without  any  necessity  for  the  use  of  that  filthy  and  undesirable 
mercurial  ointment. 


CHAPTER    XXII. 

DISEASES    OF    THE    PREGNANT    FEMALE Continued. 

THE  symptoms  or  affections  originating  from  compression  of  the 
enlarged  uterus  upon  neighboring  organs  are  several.  (Edema,  or 
serous  infiltration  into  the  cellular  tissue  of  various  parts  of  the  body, 
will  be  first  noticed.  It  may  occur  in  the  early  months  of  pregnancy, 
but  is  most  common  in  the  latter  months,  and  is  generally  attributable 
to  pressure  of  the  enlarged  uterus  upon  the  blood-vessels  of  the  pelvis, 
thereby  interrupting  the  circulation,  and  finally  resulting  in  effusion. 
It  is  not,  however,  always  produced  from  this  cause,  as  frequently  the 
size  of  the  uterus  bears  no  proportion  to  the  extent  of  the  oedema,  but 
is  usually  small;  and,  again,  wre  frequently  find  the  uterus  enormously 
distended,  either  by  excess  of  liquor  aranii  or  plurality  of  children,  with- 
out any  accompanying  oedema.  In  those  instances  where  the  swelling 
is  caused  by  uterine  pressure,  it  is  mostly  confined  to  the  lower  extrem- 
ities, but  where  it  spreads  over  the  whole  body  it  is  due  to  plethora, 


DISEASES    OF    TJTE    PREGNANT    FEMALE.  235 

or  renal  congestion,  which  may  be  known  by  the  presence  of  albu- 
minaria,  and  either  of  which  is  unfavorable.  Convulsions  are  very 
apt  to  succeed  oedema  from  these  latter  causes.  Ordinarily,  no  pain 
accompanies  this  affection,  yet,  occasionally,  it  is  very  painful.  Where 
the  swelling  is  confined  to  the  feet  and  ankles,  quickly  disappearing 
on  assuming  the  recumbent  position,  but  little  treatment  is  required; 
but  where  it  becomes  so  great  as  to  render  the  recumbent  position 
almost  impossible,  from  dyspnoea,  or  where  it  is  complicated  with 
effusion  into  any  of  the  important  cavities  of  the  body,  it  becomes  of 
a  serious  nature,  and  requires  energetic  treatment.  In  the  milder 
cases,  when  confined  to  the  lower  extremities,  and  where  treatment  is 
required,  relief  may  be  afforded  by  the  administration  of  laxatives, 
with  cold  applications  to  the  cedematous  part,  at  the  same  time  sup- 
porting the  limbs  with  a  bandage  well  applied.  The  rubber,  or 
elastic,  bandage  is  more  efficient  in  these  cases  than  if  made  from 
other  material,  as  the  degree  of  pressure  can  be  regulated,  thus  pro- 
ducing more  uniform  support.  In  severe  cases,  purgatives  and  di- 
uretics will  be  beneficial,  and  it  will  often  become  necessary  to  induce 
premature  labor  as  the  only  means  of  saving  the  patient's  life,  who 
can  not  possibly  live  up  to  the  full  period  with  an  increasing  infiltra- 
tion. When  oedema  is  not  dependent  upon  some  important  organic 
lesion,  it  usually  disappears  after  parturition.  When  renal  conges- 
tion is  a  cause  of  the  effusion,  in  addition  to  the  above  treatment  cups 
may  be  applied  over  the  region  of  the  kidneys,  and,  if  obstinate,  a 
discharge  may  be  maintained  from  this  region  by  means  of  an  irritat- 
ing plaster.  Puncturing  and  scarification  of  the  cedematous  limbs  are 
advised  by  some  authors,  but  they  should  not  be  attempted,  as  they 
are  most  usually  followed  by  gangrene. 

When,  by  pressure  of  the  enlarged  uterus  upon  the  pelvic  blood- 
vessels, the  circulation  within  the  lower  extremities  is  obstructed,  it 
gives  rise  to  a  varicose  condition  of  their  veins.  This  difficulty  is  a  fre- 
quent accompaniment  of  the  latter  months  of  utero-gestation,  and  is 
more  apt  to  occur  in  women  of  an  advanced  age,  than  in  young  females. 
As  they  are  owing  to  the  impeded  circulation  in  the  extremities,  their 
cure  can  not  be  effected  until  the  cause  is  removed,  when  they  usually 
disappear  spontaneously.  Sometimes  they  continue  after  delivery, 
gradually  increasing,  and  on  each  subsequent  pregnancy  augmenting 
considerably  in  size,  forming  tumors  which  are  more  or  less  painful, 
embarrassing  the  movements  of  the  female,  and  often  terminating  in 


*23<)  KIN<;'s    KCLKCTIC    OBSTETRICS. 

obstinate  nlcerations.  Rupture  of  these  veins  is  the  principal  acci- 
dent to  fear,  as  it  may  prove  fatal,  and  the  practitioner's  treatment 
.should  be  especially  directed  to  a  prevention  of  its  occurrence.  The 
patient  should  not  be  long  at  a  time  on  her  feet,  but  should  keep  in  a 
horizontal  position,  with  the  dress  loose,  and  the  employment  of 
properly  graduated  pressure  over  the  veins  by  means  of  bandages,  or 
elastic  stockings.  The  bowels  should  be  kept  free,  the  diet  spare,  and 
the  bandages  may  be  kept  moistened  with  cooling  applications, 
especially  in  severe  cases.  If  the  varices  are  situated  in  the  genital 
parts,  as  the  vulva  or  vagina,  compresses  moistened  with  cooling 
lotions  may  be  applied,  and  continued  for  some  time,  or  until  the 
enlargements  disappear,  in  order  to  prevent  rupture,  which  sometimes 
happens,  especially  at  the  time  of  parturition,  during  the  passage  of 
the  fetal  head  through  the  pelvic  canal.  Within  a  year  or  so,  new 
modes  of  treating  varicose  veins  have  been  suggested;  one  by  Dr. 
Linon,  in  which  he  thoroughly  moistens  a  flannel  compress  with  a 
solution  of  six  drachms  of  perchloride  of  iron  in  eight  ounces  of 
water,  applies  this  upon  the  varicose  part,  and  holds  it  there  for 
twenty-four  hours  by  means  of  a  roller  bandage  of  flannel  applied 
moderately  tight.  This  application  is  to  be  repeated  daily  for  ten  or 
twelve  days  in  succession,  or  until  the  varices  have  disappeared,  after 
which  the  bandage  may  be  continued  for  some  days  without  wetting 
the  compress.  This  is  stated  to  have  cured  enormous  varices,  accom- 
panied with  pain  and  dark  spots;  an  improvement  in  the  venous  di- 
latations will  be  observed  from  the  first  appplication.  Dr.  Rugge,  of 
Berlin,  has  met  with  success  by  subcutaneous  injections  of  one  or  two 
grains  of  Ergotin,  repeated  every  few  days,  the  varices  gradually  dis- 
appearing from  the  first  injections.  Pain  and  infiltration  followed 
each  injection,  but  were  succeeded  by  no  abscess,  nor  any  influence  in 
provoking  uterine  contractions.  The  best  vehicle  is  Glycerine,  five 
grains  of  the  Ergotin  to  one  fluid  drachm  of  this  fluid.  Prof.  Scudder 
prefers  the  Hamamelis. 

From  a  cause  similar  to  the  above,  hemorrhoids,  or  piles,  may  be 
produced,  and  more  particularly  if  constipation  be  present.  Occasion- 
ally they  are  an  attendant  of  diarrhea.  They  are  similar  in  nature  and 
appearance  to  those  occurring  at  other  times,  and  require  the  same 
local  treatment.  When  slight,  they  may  be  removed  by  producing 
regularity  of  the  bowels  by  means  of  laxative  medicines,  with  cold 
and  astringent  applications  to  the  parts.  Although  Magnesia,  as  the 


DISEASES    OF    THE    PREGNANT    FEMALE.  237 

rule,  is  contra-indicated  in  pregnancy,  on  account  of  its  tendency  to 
accumulate  in  the  intestines,  the  following  preparation  is  stated  to  be 
very  beneficial  in  procuring  daily  soft  alvine  evacuations  without 
pain :  take  of  Sulphate  of  Magnesia,  Carbonate  of  Magnesia,  Bitar- 
trate  of  Potassa,  Sublimed  Sulphur,  each,  equal  parts.  The  dose  is 
from  one  to  three  teaspoonfuls  before  breakfast,  according  to  its  action. 
Internal  agents  may  be  administered,  in  the  hope  of  overcoming  the 
trouble  by  stimulating  the  venous  circulation ;  Hamamelis  and  Col- 
linsonia  may  be  employed,  either  singly  or  in  combination,  for  this 
purpose,  and  will  oftentimes  effect  a  cure.  Owing,  however,  to  the 
fact  of  this  condition  being  the  direct  result  of  mechanical  pressure, 
therapeutic  means  do  not  always  relieve ;  the  annoyance  and  suffer- 
ing continuing  until  the  cause  is  removed  by  parturition.  If  pain  or 
irritation  exist,  narcotic  ointments,  as  Poke,  Stramonium,  etc.,  may 
be  applied  with  benefit,  and  where  the  tumor  protrudes  externally  the 
pain  and  iritation  may  be  relieved  by  the  application  of  Laudanum, 
incorporated  in  Juniper  pomade,  or  Glycerole  of  Tannin  on  absorb- 
ent cotton.  The  removal  of  piles  by  an  operation,  during  pregnancy, 
is  totally  inadmissible  and  unjustifiable.  Nor  can  a  perfect  cure  be 
expected  until  after  parturition,  when  the  pressure  has  been  removed 
by  a  return  of  the  uterus  to  its  nongravid  condition.  I  have  derived 
considerable  benefit,  in  this  difficulty,  from  an  ointment  composed  of 
Stramonium  ointment,  one  ounce,  Alum,  two  drachms,  Sulphate  of 
Morphia,  ten  grains;  mix,  and  apply  a  small  quantity  on  lint  or 
cotton.  Another  valuable  local  application  is  the  Persulphate  of  Iron. 
A  solution  of  Borax,  also,  is  a  cooling  application,  and  will  relieve 
the  itching  and  burning ;  the  parts  may  be  washed  with  it  morning  and 
evening.  An  ointment  composed  of  Tannin,  ten  grains,  Acetate  or  Mu- 
riate of  Morphia,  two  grains,  pure  Lard,  or  Spermaceti  ointment,  one 
ounce,  has  also  been  advantageously  employed  as  a  local  application. 
All  these  ointments  should  be  applied  two  or  three  times  a  day,  and 
be  carried  well  up  into  the  rectum.  Occasionally  the  pain  and  irrita- 
tion become  so  excessive  that  the  direct  application  of  anodynes  will 
be  called  for.  Cocaine  may  be  employed ;  a  four  per  cent,  solution 
will  usually  mitigate  the  suffering.  Many  other  remedies  have  been 
employed  in  piles  with  benefit,  and  others  may  suggest  themselves  to 
the  mind  of  the  practitioner,  but  whatever  local  means  may  be  used, 
it  is  of  the  greatest  importance  to  keep  the  bowels  regular,  the  diet 
spare  but  nutritious  and  easily  digested,  and  avoid  too  much  exercise, 
or  even  long  standing. 


238  KINGS    KCLKCTIC    OI'.STKTKK 'S. 

Should  hemorrhage  l>e  present,  it  must  be  checked,  especially  when 
considerable,  or  it  may  occasion  miscarriage;  for  this  purpose  astrin- 
gents, cold  applications,  and  compression  may  be  employed.  A  prep- 
aration composed  of  Stramonium  ointment,  one  ounce,  Styptic  powder 
(calcined  Sulphate  of  Iron),  two  drachms,  and  powdered  Alum,  one 
drachm,  employed  as  a  local  application,  and  introduced  as  far  as 
possible  into  the  rectum  by  means  of  the  finger  or  otherwise,  will  be 
found  very  valuable  in  all  cases  of  hemorrhoids  accompanied  with 
hemorrhage.  Persulphate  of  Iron,  diluted  about  one-half,  and  ap- 
plied on  cotton  or  lint,  will  also  act  promptly  in  controlling  the  bleed- 
ing. Injections  of  warm  water  may  be  used  for  this  purpose,  when 
other  means  are  not  at  hand.  Fluid  extract  of  Witch-hazel  bark, 
taken  internally,  has  also  proved  very  useful. 

Prolapsus  ani  is  occasionally  met  with  as  a  concomitant  of  piles,  or 
it  may  occur  independently;  it  is  often  attended  with  excessive  pain 
during  an  alvine  evacuation,  together  with  distressing  tenesmus,  and 
is  usually  produced  by  the  same  causes  which  occasion  piles,  viz.: 
pressure.  This  symptom  is  exceedingly  annoying  and  distressing, 
and  but  little  can  be  done  toward  a  cure  of  it,  until  after  delivery  is 
accomplished,  when,  as  a  general  thing,  the  cause  being  removed,  a 
spontaneous  cure  is  effected. 

With  this  complication,  the  parts  are  usually  relaxed  to  the  degree, 
that  extrusion  of  a  portion  of  the  mucous  membrane  of  the  rectum  is 
produced  by  the  slightest  causes.  It  is  cpaite  likely  to  follow  constipa- 
tion ;  in  some  cases  every  evacuation  of  the  bowels  is  followed  by  a 
return  of  the  difficulty;  straining  at  stool,  and  coughing  are  also  ex- 
citing causes.  Temporary  relief  is  all  that  can  be  expected  in  the 
way  of  treatment ;  whenever  the  prolapsus  occurs  it  should  be  returned 
as  soon  as  possible.  Place  the  patient  in  the  knee-elbow  position, 
anoint  the  fingers  before  manipulating  the  parts,  and  endeavor  care- 
fully to  return  the  part  first,  which  escaped  last.  This  is  a  simple 
operation,  and  one  the  patient  can  execute  after  a  short  time,  without 
professional  assistance.  If  painful,  the  protrusion  can  be  painted  with 
a  solution  of  Cocaine  before  an  attempt  is  made  to  return  it,  after 
which  the  parts  may  be  supported  by  passing  within  the  anus  a  pledget 
of  cotton,  which  may  be  saturated  with  Glycerole  of  Tannin,  or  other . 
mild  non-irritating  astringents.  The  female  should  be  instructed  as 
to  the  after  treatment,  in  order  to  properly  apply  it  in  subsequent 
attacks.  Prolapsus  ani  is  a  very  troublesome  affliction  during  par- 


DISEASES    OF    THE    PREGNANT    FEMALE.  239 

turition,  as  every  pain  is  apt  to  cause  a  protrusion  of  the  bowel,  ren- 
dering it  irritable  and  most  acutely  sensitive. 

Cramps  of  the  inferior  extremities,  sometimes  extending  as  high  as 
the  upper  pelvic  region,  are  occasioned  by  pressure  of  the  gravid  uterus 
upon  neighboring  nerves;  they  may  likewise  be  occasioned  by  stand- 
ing upright  for  a  long  time,  too  much  exercise,  fatigue,  constipation, 
or  extension  of  ligaments.  They  are  sudden  in  their  attacks,  are  occa- 
sionally very  frequent  and  painful,  and  mostly  occur  during  the  latter 
months  of  pregnancy.  Friction  over  the  affected  part,  and  change  of 
position  will  ordinarily  remove  them;  and  when  they  are  frequent  in 
their  attacks,  relief  can  often  be  afforded,  and  this  disposition  to  fre- 
quency obviated,  by  an  attention  to  the  bowels,  together  with  the  use 
of  Macrotys,  or  Xanthoxylum.  Viburnum  will  often  overcome  this 
trouble,  especially  if  the  patient  take  the  recumbent  position  during 
its  administration,  and  so  remain,  quietly,  until  the  paroxysm  sub- 
sides. The  application  of  a  liniment  composed  of  equal  parts  of  Aq. 
Ammonium,  Turpentine  and  Olive  oil,  will  be  found  quite  serviceable 
in  relieving  the  spasm  of  the  part.  The  soreness  caused  by  the  cramps 
may  remain  for  sometime  after  their  cessation,  and  may  be  removed 
by  rubbing  the  parts  with  some  Camphorated  oil,  or  the  officinal  com- 
pound tincture  of  Camphor.  .  Gelsemium  may  also  be  administered 
with  benefit. 

The  pregnant  female  frequently  suffers  from  a  deep  seated  pain  in 
the  right  side,  which  most  commonly  manifests  itself  after  the  fifth 
month;  it  is  unaccompanied  by  cough,  or  any  febrile  or  inflammatory 
symptoms,  and  is  attributed  to  the  fundus  of  the  uterus  pressing 
against  the  concave  surface  of  the  liver.  It  is  not  present  until  after 
the  ascent  of  the  uterus  above  the  superior  strait — never  occurs  in  left 
lateral,  or  anterior  obliquity  of  the  uterus,  but  only  in  right  lateral 
obliquity,  and  is  much  relieved,  after  the  eighth  month,  by  the  falling 
or  descent  of  the  uterus  into  the  pelvis.  Permanent  relief  can  not  be 
had  until  after  delivery,  yet  when  severe,  the  female  may  derive  con- 
siderable benefit  from  change  of  position,  standing,  lying  on  the  left 
side,  stretching  upward,  and  leaning  to  one  side ;  in  addition  to  which 
the  bowels  should  be  kept  free.  At  least  one  evacuation  should  be 
solicited  daily.  Regularity  in  going  to  stool  will  often  correct  any 
irregularity  in  this  regard.  Proper  attention  to  diet,  and  judicious 
exercise  should  be  advised.  One  drop  of  Nux  in  a  glass  of  water 


•J4»»  KING'S  ECLECTIC  OBSTETRICS. 

may  be  taken  each  morning,  or  mild  laxatives,  if  they  become  neces- 
sary. When  the  pain  is  excessively  severe,  cupping  will  sometimes 
mitigate  it.  The  diet  should  be  light  and  non-stimulant. 

Jaundice,  occasionally  occurs  during  pregnancy,  and  is  owing  to 
pressure  upon  the  gall-ducts  by  the  neighboring  viscera,  which  are 
compressed  by  the  gravid  uterus,  in  consequence  of  which  there  is  not 
a  free  escape  of  bile;  it  is  more  severe  when  it  happens  during  the 
latter  months,  and  is  usually  attended  with  dyspeptic  symptoms.  But 
little  can  be  done  for  this  evil;  though  it  .is  proper  to  regulate  the 
bowels,  and  attend  to  the  diet.  Should  it  remain  after  delivery,  it 
must  be  met  with  the  appropriate  treatment. 

Females  who  have  given  birth  to  many  children  are  sometimes 
annoyed  with  a  lax  condition  of  the  abdomen,  in  which  the  abdominal 
parietes,  from  their  excessive  looseness,  do  not  afford  support  to  the 
enlarged  uterus,  thereby  allowing  it  to  fall  in  any  direction.  The  best 
treatment,  in  such  cases,  is  a  local  application  composed  of  astringent 
and  slightly-stimulant  agents,  together  with  mechanical  support  by 
means  of  an  appropriate  belt  or  bandage,  and  the  patient  should  as- 
sume the  recumbent  position  daily,  for  three  or  four  hours  at  a  time. 

In  opposition  to  this,  we  frequently  meet  with  a  very  rigid  condition 
of  the  abdomen,  in  which  its  parietes  do  not  give  way  in  proportion  to 
the  gradual  augmentation  of  the  volume  of  the  uterus.  This  is  most 
common  among  primiparse,  occasioning  much  distress,  in  consequence 
of  the  tender  and  irritable  condition  of  the  parts,  the  skin  over  which 
often  cracks.  This  may  sometimes  be  relieved  by  rubbing  Sweet  oil, 
Almond  oil,  simple  ointment,  etc.,  over  the  part,  and  if  very  painful 
or  tender,  it  may  be  relieved  by  hot,  or  soothing  applications,  Cloths 
wrung  out  of  hot  water,  or  a  fomentation  of  Hops.  If  abrasions  exist 
the  parts  may  be  painted  with  a  solution  of  Cocaine.  Internal  treat- 
ment is  useless. 

There  are  other  symptoms  occasionally  met  with  during  pregnancy, 
which  are  due  to  pressure,  or  nervous  and  vascular  sympathetic  de- 
rangement, and  \vhich  deserve  a  passing  notice.  Thus,  in  the  latter 
months  of  pregnancy,  females  are  unable  to  retain  their  urine,  which 
escapes  upon  the  least  exertion,  and  may  or  may  not  be  accompanied 
with  tenesmus  or  a  frequent  desire  to  evacuate  the  bladder;  this  incon- 


DISEASES    OP    THE    PKEGXANT    FEMALE.  241 

tinence  of  the  urine  seldom  admits  of  relief  until  the  removal  of  the 
cause — the  pressure  of  the  bladder  by  the  enlarged  uterus — by  deliv- 
ery; perhaps,  some  benefit  may  accrue  by  giving  support  to  the  abdo- 
men. It  is  a  very  annoying  symptoin,  but  is  by  no  means  dangerous. 

Occasionally,  pustules  around  the  genital  organs  may  appear,  or 
vaginal  mucous  discharges  of  a  whitish  color,  tinged  sometimes  with 
green,  or  blood.  These  symptoms  disappear  after  delivery,  and  require 
no  other  treatment  than  cleanliness,  frequently  bathing  and  injecting 
the  parts  with  Fluid  Hydrastis,  or  solution  of  Borax,  or  other  similar 
combination.  The  practitioner  must  be  careful  not  to  injure  his  pa- 
tient's reputation  as  well  as  his  own,  by  pronouncing  either  of  these 
as  syphilitic,  on  too  slight  grounds,  for  they  are  often  the  legitimate 
results  of  pregnancy. 

Pressure  of  the  uterus  is  apt  to  occasion  congestion  of  various 
organs,  especially  of  the  lungs,  or  stomach,  in  consequence  of  which 
hemoptysis  or  hematemesis  may  result  from  exudation  of  blood  from  the 
mucous  membrane.  These  hemorrhages  may  be  treated  by  laxatives, 
sedatives,  astringents,  and  the  means  usually  employed  for  them  when 
existing  at  other  times.  Should  they,  at  the  time  of  parturition,  be- 
come excessive,  resisting  the  treatment  employed,  the  delivery  should 
be  hastened  by  artificial  means. 

There  are  likewise  symptoms  which  occur  during  utero-gestation, 
depending  upon  an  abnormal  condition  of  the  uterus,  its  supports,  or 
its  contents.  Among  the  displacements  of  the  organ,  prolapsus  or 
descent,  are  the  most  common,  and  it  usually  takes  place  during  the 
first  months,  before  the  ascent  of  the  uterus  above  the  superior  strait; 
though  it  must  not  be  forgotten  that,  during  the  early  weeks  of  preg- 
nancy, there  exists,  probably  from  an  augmentation  of  the  weight  of 
this  organ,  what  may  be  termed  a  normal  prolapsus;  but  when  it 
exceeds  this  normality  it  then  becomes  abnormal  and  demands  treat- 
merit.  The  patient  will  complain  of  a  bearing-down  sensation,  with 
pain  and  uneasiness  in  the  sacral  region,  and  frequently  in  the  lower 
part  of  the  abdomen.  The  prolapsus  will  be  more  or  less  perfect  ac- 
cording to  the  capaciousness  of  the  pelvis,  and  the  laxity  of  the  liga- 
ments. Where  there  is  an  excess  of  pelvic  dimension,  a  sudden 
prolapsus  may  take  place  in  an  advanced  stage  of  pregnancy,  from 
straining,  over-exercise,  or  some  unusual  exertion.  This  displacement 
not  only  occasions  abortion,  but  is  frequently  caused  by  it,  from  the 
16 


242  KING'S  ECLECTIC  OBSTETRICS. 

uterus  being  left  in  an  inflamed  or  hypersemic  condition ;  it  may  also 
be  produced  by  straining,  debility,  and  whatever  circumstances  would 
give  rise  to  it  in  the  uuimpregnated  state.  This  difficulty  may  give 
rise  to  very  serious  evils,  and  should  be  promptly  treated.  Ordinarily, 
the  employment  of  astringent  vaginal  enema,  rest  in  the  recumbent 
position,  the  wearing  of  external  supports  or  bandages,  and  regularity 
in  the  evacuations  from  the  bladder  and  bowels,  will  answer  the  pur- 
pose. In  very  severe  and  obstinate  cases  other  measures  may  be 
required;  the  rectum  and  bladder  should  first  be  evacuated;  the  pro- 
lapsed organ  should  then  be  carefully  placed  in  its  proper  position, 
and  retained  there  by  a  piece  of  fine  sponge  introduced  into  the  vagina, 
and  the  patient  should  maintain  as  much  as  possible  the  recumbent 
position,  until  the  increased  volume  of  the  uterus  would  prevent  any 
further  prolapse.  The  sponge  may  be  moistened  with  some  astringent 
lotion,  if  desired,  and  should  be  cleansed  every  two  or  three  days. 
Any  accompanying  symptoms,  as  debility,  constipation,  etc.,  must  be 
met  by  appropriate  treatment.  If  the  mechanical  treatment,  by  sponge 
or  other  pessary,  occasions  irritation,  increased  suffering,  or  pain,  it 
will  have  to  be  omitted,  and  the  preceding  measures  be  pursued. 
AVhen  we  find  an  impaction  of  the  uterus  within  the  pelvis,  render- 
ing its  reduction  impossible,  abortion  will  have  to  be  induced. 

Retroversion  of  the  gravid  uterus,  is  sometimes  met  with,  as  well  as 
in  the  unimpregnated  organ ;  in  this  displacement,  the  fundus  is  found 
backward,  at  or  below  the  promontory  of  the  sacrum,  while  the  os 
tincse  is  carried  forward  and  upward,  either  upon,  or  above  the  pubic 
symphysis,  and  the  vagina  being  dragged  along  with  the  os,  its  ante- 
rior wall  will  be  likewise  carried  forward  and  upward,  while  its  pos- 
terior wall  will  be  considerably  depressed.  Retroversion  of  the  uterus 
may  come  on  slowly  or  suddenly,  it  seldom  exists  in  the  latter  months 
of  pregnancy,  and  usually  takes  place  between  the  second  and  fourth 
months.  It  may  be  owing  to  various  causes;  a  very  common  one  is 
a  retention  of  urine  until  the  bladder  becomes  enormously  distended, 
which  extending  backward  and  downward,  thrusts  the  uterine  fundus 
along  with  it  in  the  same  direction ;  or  a  large  pelvis  may  predispose 
to  this  accident,  but  it  is  not  an  essential  condition ;  relaxed  condition 
of  the  uterine  supports,  augmented  weight  of  the  fundus  with  relaxa- 
tion of  the  parts,  great  concavity  of  the  sacrum,  ovarian  enlargement, 
tumors,  violent  efforts,  straining  at  stool,  blows,  falls,  vomiting,  poly- 
pus, hydatids,  etc.,  are  each  capable  of  effecting  this  displacement 


DISEASES    OF    THE    PREGNANT    FEMALE.  243 

under  favorable  circumstances.  The  symptoms  accompanying  retro- 
version  are,  a  partial  or  complete  retention  of  urine,  which  often  takes 
place  suddenly ;  when  it  is  partial  there  is  a  desire  to  urinate  frequently, 
the  water  passes  off  in  small  quantities  at  a  time,  but  never  in  suffi- 
cient amount  to  empty  the  bladder,  and  finally,  it  involuntarily  drib- 
bles away,  and  the  enormous  distension  of  the  bladder  creates  a  chronic 
inflammation,  or  what  is  yet  worse,  it  may  become  ruptured.  Defe- 
cation is  also  very  difficult,  the  feces  being  flattened  and  passing  in 
small  quantities;  and  both  the  dysuria  and  difficult  defecation  are  in- 
creased by  any  efforts  at  evacuation.  When  retention  of  urine  is  pres- 
ent in  the  early  months  of  pregnancy,  the  practitioner  should  suspect 
retroversion,  and  adopt  the  proper  means  to  satisfy  himself  in  relation 
to  it.  In  connection  with  these  two  prominent  symptoms,  there  wrill 
be  an  aching  pain  in  the  sacrum,  thighs,  and  pubes,  with  weight  in 
the  pelvis  and  disagreeable  bearing-down  sensations.  When  retrover- 
sion is  suspected  in  the  pregnant  female,  an  examination  should  be 
immediately  demanded,  for  if  it  be  not  promptly  attended  to,  it  may 
occasion  the  death  of  both  the  mother  and  child,  as  may  be  readily 
imagined,  when  an  enlarging  uterus  becomes  impacted  in  the  cavity 
of  the  pelvis,  preventing  micturition  by  its  pressure  upon  the  urethra, 
causing  irremediable  constipation  by  compression  of  the  rectum,  and 
intense  suffering  by  pressure  upon  the  anterior  sacral  foramina  and 
nerves.  Upon  an  examination  per  vaginam,  which  must  in  all  cases 
be  made,  the  uterine  fundus  will  be  found  depressed  below  the  prom- 
ontory of  the  sacrum,  with  the  cervix  toward  the  bladder,  and  higher 
than  the  crown  of  the  pubic  arch;  in  some  instances,  the  os  uteri  may 
be  found  in  its  normal  position,  with  the  fuiidus  depressed,  the  cervix 
being  bent  or  flexed  at  an  angle,  in  which  the  uterus  is  shaped  some- 
what like  a  retort;  this  is  termed  retroflexion,  and  is  not  common  in 
the  pregnant  condition.  If  this  displacement  be  not  relieved,  the  pains 
continue  to  increase,  vomiting  takes  place,  with  peritonitis,  and  the 
patient  dies  from  inflammation  or  sloughing ;  and  it  must  be  remem- 
bered, that  the  later  the  gestating  period  in  which  the  retroversion 
occurs,  the  greater  is  the  danger. 

In  treating  a  case  of  this  character,  before  any  attempt  at  reduction 
is  made,  the  bladder  must  be  emptied  by  means  of  a  male  elastic 
catheter,  bearing  in  mind  that  the  displaced  uterus,  having  elevated 
the  neck  of  the  bladder,  causes  an  elongation  of  the  urethra.  Some- 
times considerable  difficulty  will  be  experienced  in  introducing  the 
catheter,  which  may  be  overcome  by  pressing  the  uterus  backward, 


244  KING'S  ECLECTIC  OBSTETRICS. 

and  thus  liberating  the  urethra,  until  the  instrument  has  entered. 
Soon  after  the  evacuation  of  the  bladder  it  will  often  be  found  that 
the  uterus  assumes  its  normal  position  without  further  interference; 
should  this  not  take  place,  the  rectum  must  be  unloaded  by  copious 
injections,  as  an  accumulation  of  fecal  matter  within  it  will  very  much 
interfere  with  the  attempt  to  replace  the  uterus  properly.  Though  it 
should  be  stated  that  injections  have  sometimes  failed  to  produce  the 
desired  effect,  and  instead  of  relieving  has  aggravated  the  difficulty. 
The  patient  is  now  to  be  placed  upon  her  face,  or  the  operation  may 
be  performed  while  she  lies  on  her  left  side,  with  the  nates  near  the 
edge  of  the  bed,  and  two  fingers  be  passed  into  the  posterior  part  of 
the  vagina  along  the  curve  of  the  sacrum,  until  they  come  in  contact 
with  the  presenting  part  of  the  depressed  fundus,  which  must  be  pressed 
cautiously  and  firmly  upward  and  forward,  in  the  direction  of  the  axis 
of  the  superior  strait;  for  if  the  pressure  be  made  in  any  other  course, 
no  reduction  can  be  accomplished.  When  the  reduction  is  effected, 
the  womb  assumes  its  position  with  a  sudden  jerk,  and  sometimes  a 
clicking  noise.  Sometimes  this  attempt  will  fail ;  it  will  then  be 
proper  to  introduce  one  or  two  fingers  into  the  rectum  for  the  purpose 
of  pushing  the  fundus  upward  and  forward,  while  a  finger  or  two  of 
the  other  hand  enters  the  vagina,  for  the  purpose  of  bringing  down 
or  depressing  the  cervix,  and  all  these  trials  should  be  made  steadily, 
cautiously,  and  firmly.  In  very  obstinate  cases,  the  patient  may  be 
placed  on  her  knees,  "having  the  pelvis  elevated  as  high  as  possible, 
while  the  shoulders  rest  upon  the  bed,  table,  or  whatever  she  is  placed 
upon,  and  in  this  position,  having  the  aid  of  gravitation,  we  may 
undertake  the  last  named  manipulation;  this  posture  is  a  favorable 
one,  inasmuch  as  it  tends  to  overcome  tenesmus  and  bearing-down 
efforts.  Various  other  means  have  been  advised  to  reduce  the  retro- 
verted  organ  as  the  use  of  Bond's  instrument  for  retroversion ;  Gariel's 
India-rubber  pessary,  etc.,  and  to  produce  a  thorough  muscular  relaxa- 
tion, the  use  of  Chloroform,  or  Hydrate  of  Chloral. 

Having  accomplished  reduction,  the  patient  should  be  kept  in  a 
recumbent  state,  until  the  ascent  of  the  uterus  above  the  promontory, 
when  its  volume  has  so  far  augmented  as  to  render  any  further  dis- 
placement of  the  kind  impossible;  and  the  bladder  should  likewise  be 
emptied  every  four  or  five  hours .  If  necessary,  anodynes  or  tonics 
may  be  given  according  to  the  indications.  Instances  are  sometimes 
met  with,  in  which,  afcer  the  organ  has  been  reduced,  it  will  not  re- 
main so,  but  falls  over  again  upon  the  slightest  exertion,  and  the 


DISEASES    OF    THE    PREGNANT    FEMALE.  245 

operation  will  have  to  be  performed  again  and  again  before  the  reduc- 
tion will  remain  permanent.  In  these  cases  advantage  has  ensued 
from  the  introduction  of  a  thin  gum-elastic  air  bag,  of  a  fusiform 
shape,  into  the  rectum;  the  large  end  of  this  to  be  introduced,  after 
which  it  is  to  be  distended  with  air,  and  constantly  worn  by  the 
patient,  until  no  longer  required ;  it  admits  of  easy  removal  at  auy 
time  by  permitting  the  inclosed  air  to  escape,  and  then  withdrawing  it. 

The  reduction  of  the  uterus  may  only  be  partial,  so  that  although 
remaining  in  the  pelvis,  a  part  ascends,  giving  the  organ  a  deformed 
shape,  still  an  attention  to  the  bladder  and  rectum  may  enable  the 
patient  to  reach  the  full  term ;  in  these  cases  the  labor  may  be  com- 
pleted without  artificial  aid,  though  it  may  be  tedious  and  difficult. 

Where  retroversion  has  occurred  previous  to  pregnancy,  and  the 
organ  is  rendered  almost  immovable  by  adhesions,  or  where  from 
other  causes,  after  a  persevering  attention  to  the  bladder  and  rectum, 
no  permanent  reduction  can  be  obtained,  it  has  been  proposed  to 
induce  premature  labor  as  the  only  means  of  saving  life  ;  but  \ve  must 
be  cautious  in  a  resort  to  this  expedient,  and  should  never  undertake 
it  without  the  opinion  of  a  second  or  even  third  practitioner. 

In  anteversion  of  the  uterus,  the  displacement  is  exactly  contrary  to 
the  last ;  the  fundus  pressing  forward  toward  the  symphysis  pubis, 
near  the  level  of  the  superior  strait,  while  the  cervix  is  thrown  back- 
ward and  upward,  the  os  uteri  looking  toward  the  hollow  of  the 
sacrum.  This  may  originate  from  severe  exertion  while  the  bladder 
is  empty,  and  is  more  apt  to  ensue  when  the  ligaments  are  in  a  relaxed 
condition — from  blows,  falls,  tumors,  diarrhea,  relaxed  abdomen,  fecal 
accumulations,  lifting  heavy  weights,  violent  exercise,  etc.  The  symp- 
toms are,  a  constant  desire  to  pass  urine,  which  is  accomplished  with 
some  difficulty  and  heat;  constipation  is  frequently  present,  with 
pelvic  heaviness,  hypogastric  pain,  and  a  distressing,  dragging  sensa- 
tion, which  is  augmented  by  standing  or  walking.  It  is  rarely  present 
during  pregnancy,  and  wrhen  it  does  occur  is  not  so  serious  as  retro- 
version.  The  treatment  is :  after  placing  the  patient  on  her  back,  to 
elevate  the  fundus  and  pull  down  the  cervix  with  a  finger,  or  hook, 
and  afterward,  if  required,  a  bandage  may  be  worn,  with  a  compress 
over  the  pubes ;  the  bowrels  should  be  kept  open,  but  the  urine  should 
not  be  passed  too  frequently.  The  woman  should  remaiiwlying  upon 
her  back  for  several  days  or  weeks,  as  may  be  required ;  though  from 
the  debility  following  a  prolonged  confinement  of  this  kind,  I  gen- 


246  KING'S  ECLECTIC  OBSTETRICS. 

erally  advise  more  or  less  exercise,  according  to  circumstances,  the 
uterus  being  held  in  place  by  a  bandage,  and  proper  support  for  the 
time  being. 

An  aqueous  discharge,  of  a  limpid,  or  yellow  color,  sometimes  takes 
place  during  pregnancy,  being  variable  in  quantity,  at  times  passing 
by  drops,  and  again  occurring  suddenly  and  in  large  amount.  It  is 
called  hydrorrhea,  or  false  waters.  Usually  this  is  not  a  serious  affec- 
tion, but  occasionally  uterine  contractions  of  a  severe  character  accom- 
pany it,  which,  if  not  overcome,  will  result  in  the  premature  expulsion 
of  the  uterine  contents.  As  regards  the  source  from  which  this  fluid 
originates,  we  have  no  satisfactory  evidence ;  authors  vary  in  opinion 
concerning  it,  some  considering  it  to  be  the  result  of  an  uterine  dropsy, 
others  to  a  transudation  of  the  amniotic  fluid  through  the  membranes, 
some  again  to  a  rupture  of  the  allantois,  or  rupture  of  the  chorion,  and 
caduca,  etc.  Most  generally,  the  woman  goes  on  to  the  full  term  of 
utero-gestation.  Where  there  is  danger  of  miscarriage,  the  bowels 
should  be  kept  in  a  soluble  condition  by  mild  laxatives  or  injections, 
the  patient  should  be  enjoined  to  keep  in  a  state  of  rest  in  the  recum- 
bent position  and  agents  administered  to  allay  any  uterine  excitement, 
among  which  I  prefer  the  compound  powder  of  Ipecacuanha  and 
Opium.  As  soon  as  any  danger  of  premature  labor  has  passed  away, 
the  patient  should  take  the  Parturient  Balm,  or  Macrotys,  for  the  pur- 
pose of  imparting  tonicity  to  the  reproductive  organs,  in  connection 
with  chalybeates  if  anaemia  be  present.  When  a  symptom  of  this 
character  attacks  a  pregnant  female,  the  practitioner  should  be  careful 
to  ascertain  the  condition  of  the  bladder,  as  not  unfrequently  a  dis- 
charge of  urine  may  be  mistaken  for  it. 

Not  unfrequentfy  the  uterus  is  attacked  with  spasmodic  action — the 
organ  may  be  felt  rapidly  moving  from  side  to  side,  with  frequent 
convulsive  movements,  and  will  speedily  induce  premature  labor  if  not 
relieved.  I  find  it  the  best  treatment  in  these  cases,  to  evacuate  the 
rectum  by  enema,  and  the  application  of  heat  to  the  part,  as  cloths 
wrung  out  of  hot  water,  while  internally  such  agents  as  Macrotys, 
Lobelia  or  Gelsemium  may  be  given.  Anodyne  liniments  may  also 
be  rubbed  on  the  abdomen. 

The  impregnated  uterus  is  sometimes  attacked  with  rheumatism, 
commonly  produced  by  the  same  causes  which  give  rise  to  rheuma- 
tism of  other  parts.  It  is  most  common  to  those  of  a  rheumatic  dia- 


DISEASES    OF    THE    PREGNANT    FEMALE.  247 

thesis,  and  is  frequently  a  metastasis  of  the  pain  from  some  other  part. 
The  symptoms  are  pain,  augmented  sensibility  of  the  uterus,  which 
may  be  limited  to  only  a  part  of  the  organ,  or  extend  over  the  whole 
of  it,  no  contractions,  pressure  often  increases  the  pain,  which  may 
extend  into  the  loins,  groins,  and  thighs,  or  which  may  suddenly  be 
translated  to  some  other  part  of  the  system.  There  is  tenesmus  or  a 
constant  desire  to  evacuate  the  bladder  and  rectum. 

To  remove  this  last  condition,  Eryngium,  Gelsemium,  or  Rhus,  may 
be  employed,  together  with  the  hot  hip  bath.  Rheumatism  as  a  rule 
will  be  attended  with  more  or  less  fever;  the  treatment,  then,  should 
begin,  by  selecting  the  proper  sedative  in  combination  with  anti-rheu- 
matics; thus  Aconite  and  Macrotys  may  be  called  for,  or  the  pulse 
being  full  and  strong,  Veratrum  should  be  used  in  place  of  the  Aco- 
nite, or  one  of  the  other  anti-rheumatics  being  indicated,  it  replaces 
the  Macrotys.  The  anti-rheumatics  in  common  use  are  the  Macrotys, 
Bryonia,  Apocynum,  Phytolacca,  Sticta,  Colchicum,  Rhus,  and  Eupa- 
torium;  Acetate  of  Potassa  and  Asclepias  are  also  useful  in  some 
cases.  Within  a  few  years  several  new  agents,  derivities  of  coal  tar, 
have  been  introduced  to  overcome  pain;  they  are  known  as  Antipy- 
rine,  Antifebrine,  Antikamnia,  as  well  as  several  others;  they  should 
be  given  with  care,  and  their  action  studied ;  they  are  positively 
contra-indicated  in  weakened  heart  action.  Quinia  is  often  a  useful 
agent,  administered  after  secretion  is  established.  The  alkalies  and 
acids  often  prove  valuable  anti-rheumatics,  especially  the  alkaline 
diuretics.  Baths,  in  these  cases,  are  usually  more  harmful  than 
beneficial. 

The  movements  of  the  fetus  in  utero,  are  sometimes  very  violent,  or 
turbulent,  not  only  occasioning  alarm  to  the  mother,  but  much  uneasi- 
ness, a  sense  of  sickness,  with  general  nervous  agitation,  sleeplessness, 
febrile  symptoms,  and  often  local  pain. 

This  may  be  owing  to  an  irritability  of  the  nervous  system,  or  to 
some  preternatural  susceptibility  of  the  uterus.  It  may  be  removed 
by  an  attention  to  the  bowels,  and  the  administration  of  Viburnum, 
Pulsatilla,  Macrotys,  or  Gelsemium,  either  singly  or  in  such  combina- 
tion as  indications  may  direct;  the  Parturient  Balm  will  frequently 
prove  beneficial ;  and  when  obstinate,  a  few  doses  of  the  compound 
powder  of  Ipecacuanha  and  Opium  may  be  given.  However,  the 
practitioner  should  bear  in  mind,  that  narcotics  should  be  employed 
as  seldom  as  possible,  during  pregnancy,  on  account  of  their  deleteri- 


248  KIND'S  i-:<  LKCTIC  OBSTETRICS. 

ous  influence  upon  the  nervous  system  of  the  fetus.  The  agents,  as 
named  above,  will,  as  a  rule,  act  promptly  in  overcoming  the  trouble, 
and  should  be  used  in  preference. 

Dropsy  of  the  ovum  usually  takes  place  during  the  early  months,  and 
may  be  suspected  by  an  unnaturally  great  increase  in  the  size  of  the 
abdomen,  which  comes  on  suddenly,  thereby  differing  from  the  gradual 
enlargement  in  ascites,  and  which  is  rendered  still  more  certain  when 
the  pregnancy  is  positively  determined.  It  is  frequently,  however, 
very  difficult  to  form  a  correct  diagnosis,  and  some  of  our  oldest  and 
most  experienced  practitioners  have  been  mistaken  in  relation  to  it. 
Abortion  is  the  common  result,  the  fetus  generally  perishing  before 
this  accident  occurs,  especially  if  the  collection  of  the  fluid  is  great; 
and  should  it  be  born  alive,  it  seldom  survives  a  few  days,  or  weeks  at 
farthest.  The  only  treatment,  in  this  affection,  is  strict  attention  to 
the  health  of  the  female,  and  an  absolute  avoidance  of  the  operation 
of  paracentesis ;  for  no  practitioner  is  justified  in  performing  this 
operation  on  a  female  who  affords  the  smallest  possible  suspicion  of 
pregnancy ;  at  least  until  a  sufficient  time  has  elapsed  for  its  determi- 
nation by  the  positive  signs,  as  revealed  by  auscultation,  ballotteraerit, 
etc.  When  the  quantity  of  fluid  is  enormous,  giving  rise  to  serious 
consequences,  the  propriety  of  inducing  premature  labor  by  evacuating 
the  amniotic  liquid,  may  then  be  considered.  Hemorrhage  and  Abor- 
tion will  be  treated  of  in  the  following  chapters. 

The  accidental  concomitants  of  pregnancy,  are  hernia,  tumors,  syphi- 
litic affections,  calculus,  deformed  pelvis,  and  extra-uterine  pregnancy  ;  the 
latter  two  have  already  been  treated  upon,  the  others  require  no  espe- 
cial consideration  at  this  place;  they  will  be  again  referred  to  under 
the  head  of  Labor.  The  treatment  for  syphilitic  affections  will  be  the 
same  as  pursued  under  other  circumstances,  independent  of  pregnancy. 


HEMORRHAGE    AND    ABORTION.  249 

CHAPTER    XXIII. 

HEMORRHAGE     AND     ABORTION. 

WHEN  the  fetus  is  capable  of  continuing  its  existence,  independent 
of  any  uterine  connection,  it  is  said  to  be  viable;  and  the  period  of  its 
viability,  theugh  not  precisely  fixed,  is  generally  admitted  as  early  as 
at  the  commencement  of  the  seventh  month.  There  are,  however,  a 
few  instances  on  record  where  children,  born  as  early  as  the  commence- 
ment of  the  sixth  month  have  been  reared,  but  these  may  be  considered 
as  the  exceptions  to  the  general  rule.  A  fetus  may  move  at  birth,  but 
this  does  not  constitute  viability.  In  cases  where  it  is  non-viable,  or 
incapable  of  sustaining  an  extra-uterine  existence,  that  is,  previous  to 
the  seventh  month,  and  is  expelled  from  the  uterus,  owing  to  any 
cause  whatever,  an  abortion  is  said  to  have  taken  place.  Its  expulsion 
at  any  time  between  the  seventh  month  and  full  term,  is  a  premature 
delivery ;  and  the  term  miscarriage  is  popularly  applied  to  either  of 
these,  indiscriminately,  and  generally  conveys  an  idea  of  loss  of  off- 
spring previous  to  the  ninth  month. 

As  hemorrhage  and  abortion  are  intimately  related,  being  generally 
dependent  on,  or  connected  with  each  other,  I  will  consider  them  under 
one  head.  Hemorrhage  may  take  place  at  any  period  of  pregnancy, 
and  is  owing  to  a  greater  or  less  detachment  of  the  ovum  from  the 
uterus,  and  the  more  extensive  the  detachment,  the  greater  is  the 
probability  of,  or  disposition  to  abortion.  In  the  earlier  months,  life  is 
seldom  endangered  by  hemorrhage,  in  consequence  of  the  smallness  of 
the  uterine  blood-vessels,  which  tlo  not  admit  of  a  large  and  rapid  dis- 
charge of  blood  ;  but  in  the  latter  months,  where  these  vessels  have 
become  much  augmented  in  size,  there  is  always  danger  from  the 
hemorrhage  which  may  then  occur.  It  should  be  stated  here,  that 
women,  laboring  under  hemorrhage  in  the  earlier  months,  are  occa- 
sionally lost,  the  flooding  obstinately  resisting  all  treatment ;  this  is 
more  usual  with  debilitated  or  anaemic  individuals,  especially  those  who 
have  had  previous  discharges,  with  large  loss  of  blood. 

Abortion  may  be  spontaneous,  accidental,  or  designed,  and  may 
occur  at  anytime  prior  to  the  seventh  month,  but  more  frequently  about 
the  third  or  fourth  month,  and  generally  at  a  period  coincident  with 
what  would  otherwise  have  been  a  menstrual  period  ;  this  is  undoubt- 


ECLECTIC    OI5STETKICS. 

edly  owing  to  the  delicate  connection  existing  between  the  ovum  and 
uterus  at  this  time,  Avhereby  a  separation  of  the  former  may  ensue 
more  readily  from  even  slight  causes  than  in  the  latter  months,  when 
this  connection  is  more  persistent.  Abortion  is  not  usually  a  serious 
accident,  as  many  females  abort  several  times,  successively,  and  few 
women  who  bear  offspring  pass  through  their  menstrual  life  without 
aborting  one  or  more  times.  The  principal  dangers  are  from  excessive 
hemorrhage,  or  the  constitutional  injury  inflicted  by  a  series  of  suc- 
cessive abortions.  The  causes  of  this  accident  are  numerqus,  and  have 
been  divided  into  constitutional,  or  depending  upon  the  condition  of 
the  maternal  health ;  ovuline,  or  attributable  to  some  disease  of  the 
ovum ;  uterine,  or  originating  from  an  abnormal  state  of  the  uterus 
and  its  appendages;  and  accidental,  or  owing  to  circumstances  not 
immediately  connected  with  the  condition  of  the  uterus,  ovum,  or 
mother. 

No  particular  class  of  females  are  especially  liable  to  abortion ;  it 
occurs  among  those  who  enjoy  the  idle,  sedentary,  luxurious  habits  of 
fashionable  life,  and  among  those  who  are  obliged  to  earn  their  daily 
subsistence  by  hard  labor ;  the  most  robust  may  abort  as  well  as  those 
of  a  delicate  and  nervous  disposition ;  though  it  may,  probably,  be 
more  frequently  observed  among  those  who  neglect  an  attention  to  the 
rules  of  hygiene.  Authors  state  that  plethoric  females,  those  who  are 
nervous  or  irritable,  or  extremely  susceptible  to  external  impressions, 
and  those  of  indolent  habits,  abort  more  frequently  than  others  ;  it  has 
likewise  been  stated  that  abortion  may  occur  as  an  epidemic.  The  con- 
stitutional causes  are  tuberculous  diseases,  as  scrofula,  anemia,  phthisis, 
and  recent  cutaneous  affections,  epilepsy,  hysteria,  abdominal  tumors, 
leucorrhea,  diarrhea,  dysentery,  constipation,  strangury,  or,  measles, 
scarlatina,  pelvic  peritonitis,  typhoid  fever,  small-pox,  and  other  acute 
diseases.  Syphilis  is  likewise  a  common  cause.  Among  these  causes, 
when  they  occur,  probably,  syphilis,  epilepsy,  small-pox,  and  scarlet 
fever,  are  the  most  certain.  Ascarides,  piles,  or  other  diseases  of  the 
rectum,  as  well  as  of  the  bladder,  ovaries,  and  kidneys,  by  the  irrita- 
tion they  communicate  to  the  uterus,  may  likewise  become  causes. 

Females,  during  pregnancy,  or  even  after  a  recent  confinement, 
should  never  be  vaccinated,  because  in  either  case  it  exposes  them  to 
great  hazard ;  this-  is  a  point  to  which  especial  attention  should  be  paid, 
not  only  on  account  of  the  abortion  which  would  very  probably  follow, 
in  the  first  condition,  but,  in  either,  violent  fever  or  inflammation  of 
the  veins,  might  be  produced,  resulting  in  death. 


HEMORRHAGE    AND    ARORTIOX.  251 

The  ovuliue  causes  are  numerous;  thus,  the  fetus  may  be  affected 
with  the  parental  diseases,  as  measles,  small-pox,  scarlatina,  lead  pois- 
oning, mercurial  salivation,  typhus,  etc.,  which  may  either  occasion 
its  death,  or  cause  its  attachment  to  the  uterus  to  become  so  delicate 
as  to  render  abortion  unavoidable.  Syphilitic  disease  may  be  commu- 
nicated to  the  ovum  by  the  male  parent,  as  well  as  the  female ;  and  a 
seminal  fluid  vitiated  by  debauchery,  or  having  its  vitality  enfeebled 
by  age,  may  also  give  rise  to  an  unhealthy  embryo,  the  result  of  which 
will  be  an  abortion.  Atrophy,  also  hypertrophy  of  the  placenta,  may 
so  debilitate  its  connection  with  the  uterus  as  to  become  a  cause  of 
this  accident.  An  effusion  of  blood  between  the  placenta  and  uterus, 
termed  by  M.  Cruveilhier  placental  apoplexy,  may  separate  the  pla- 
cental  connection,  and  give  rise  to  abortion  ;  placentitis,  hydatids, 
syphilitic  or  fatty  degeneration  of  the  placenta  or  chorion,  rupture  of 
the  umbilical  vein,  etc.,  will  also  produce  it.  Whenever  the  fetus  is 
dead,  from  whatever  cause,  it  becomes  a  foreign  body,  excites  uterine 
contraction,  and  must  inevitably  be  expelled,  though  frequently  some 
time  may  pass  between  its  death  and  expulsion.  Other  diseases  of 
the  embryo  or  its  appendages  as,  hydrocephalus,  pulmonary  disease, 
disease  of  the  chorion  or  amnion,  etc.,  may  likewise  occasion  abortion. 
Indeed,  it  is  supposed,  that  the  most  common  causes  of  this  accident, 
are  those  referable  to  the  condition  of  the  ovum. 

Among  the  uterine  causes  are,  prolapsus,  retroversion,  anteversion, 
adhesions,  uterine  irritability,  uterine  congestion,  fibroid  tumors,  poly- 
pus, cancer  of  the  cervix,  diseases  of  .the  tubes  or  ovaries,  ulceration 
of  the  cervix,  corroding  ulcer,  etc.  Madam  Boivin  found  that,  among 
a  great  proportion  of  those  females  who  habitually  aborted  at  a  regu- 
lar period  of  utero-gestation,  dissections  revealed  uterine  adhesions  to 
the  bladder,  rectum,  or  other  neighboring  organs ;  of  course,  if  these 
adhesions  are  considerable,  there  can  be  but  little  expectations  of  cure. 

The  accidental  causes  are  falls,  blows,  coitus,  severe  exercise,  lifting 
heavy  weights,  working  on  sewing  machines,  rough  motion  on  horse- 
back, in  carriages,  or,  in  railroad  coaches,  or  violent  concussion  of  the 
body  from  jumping;  and  the  membranes'of  the  ovum  may  be  so  frail 
as  to  rupture  upon  a  very  slight  compression  of  the  uterus,  occasioned 
by  coughing,  sneezing,  extracting  a  tooth,  or  straining  at  the  stool. 
Abortion  is  also  occasioned  by  emesis,  drastic  purgation,  tight-lacing, 
terror,  grief  or  excess  of  joy,  together  with  the  criminal  means  fre- 
quently employed  for  this  purpose.  It  is  unnecessary  to  enter  into 
a  detailed  relation  of  these  causes,  as  they  can  seldom  be  obviated 
by  the  practitioner,  whose  principal  efforts  will  be  directed  toward 


252  KING'S  ECLECTIC  OBSTETRICS. 

preventing  their  results  from  becoming  dangerous.  Some  women  abort 
from  the  slightest  causes,  while  with  others  again,  the  most  serious 
accidents  produce  no  influence  of  this  kind.  It  is  stated  that  abortion 
has  been  caused  by  the  mere  smelling  of  a  pungent  odor,  but  I  pre- 
sume such  instances  must  be  very  rare.  Among  newly-married 
jxT.-oiis,  abortions  frequently  occur  from  the  abuse  of  coition,  and  this 
will  likewise  prove  a  very  fertile  cause  of  the  accident  among  child- 
bearing  females  at  any  period,  especially  when  they  have  some 
displacement  or  disease  of  the  uterus;  and  I  am  fully  of  the  opinion 
that  what  are  termed,  "abortions  from  habit,"  are  chiefly  due  to  this 
act.  A  recent  author  claims  that  fully  one-half  the  spontaneous  abor- 
tions 'are  directly  the  result  of  excessive  sexual  indulgence  during 
pregnancy.  As  a  general  rule,  it  may  be  observed,  that  when  the 
ovum  is  healthy,  and  its  placental  connection  is  firm,  the  production 
of  abortion  in  a  pregnant  female  will  be  found  very  difficult  to  effect, 
except  it  be  attempted  by  some  mechanical  means,  when  it  will  be 
apt  to  assume  its  more  serious  character;  but  if  the  ovum  be  diseased, 
the  tendency  to  abort  will  be  in  proportion  to  the  influence  of  the 
disease  upon  it,  and  its  placental  connection  with  the  uterus. 

Abortion  is  undoubtedly  produced  by  the  mammary  irritation  result- 
ing from  continued  lactation  during  pregnancy;  and  with  many 
females,  conception,  as  well  as  menstruation,  is  retarded  while  the 
child  continues  to  suck.  But  whenever  the  menses  appear  during  suck- 
ling, the  child  should  be  immediately  weaned,  both  for  its  own  advant- 
age as  well  as  that  of  its  mother ;  and  the  same  course  should  be 
adopted  when  pregnancy  happens.  Frequently,  a  threatened  abortion 
may  be  checked,  and  the  female  be  enabled  to  reach  full  term,  by 
immediately  weaning  the  child  upon  the  first  appearance  of  pain  or 
bloody  discharges. 

The  symptoms  of  abortion  are  very  much  modified  by  the  causes 
which  produced  it,  and  the  period  of  pregnancy  at  which  it  occurs. 
If  it  happens  during  the  first  days  of  pregnancy,  it  is  accompanied  by 
little  or  no  pain,  and  is  often  mistaken  by  the  female  for  a  difficult 
menstruation ;  and  the  ovum  which  usually  passes  away  entire,  and 
accompanied  by  a  greater  or  less  amount  of  blood,  is  looked  upon 
merely  as  a  coagulum  or  clot.  When  the  pregnancy  is  more  advanced, 
and  especially  when  the  abortion  proceeds  slowly  and  gradually,  vari- 
ous premonitory  symptoms  may  present  themselves,  as  a  feverish  or 
irritable  condition  of  the  system,  loss  of  appetite,  nausea,  cold  extremi- 
ties, swelling  of  the  eyelids,  with  lividity,  mental  depression,  intermit- 
tent pains  in  the  loins,  a  sensation  of  weight  about  the  vulva,  frequent 


HEMORRHAGE    AND    ABORTION.  253 

desire  to  urinate  or  defecate,  and  flaccidity  of  the  breasts;  the  pains 
continue  to  increase  in  frequency  and  force;  they  extend  over  the 
abdomen,  running  toward  the  coccyx,  and  finally  assume  the  characters 
of  true  uterine  contractions.  A  sanious  and  bloody  vaginal  discharge 
takes  place,  and,  as  the  pains  continue,  the  dilatation  of  the  os  uteri 
progresses,  the  membranes  protrude,  become  ruptured,  the  liquor 
amnii  escapes,  and,  sooner  or  later,  the  ovum,  either  entire  or  in  part, 
i.s  expelled.  As  all  these  symptoms,  with  the  exception  of  rupture  of 
the  membranes,  may  occur  in  pregnancy  without  any  subsequent  abor 
tion,  the  practitioner  must  be  guarded  in  his  diagnosis,  unless  he 
knows  positively  that  the  fetus  is  dead. 

Most  frequently,  however,  there  are  no  precursory  or  constitutional 
symptoms;  the  first  sign  being  the  hemorrhage,  which  is  more  or  less 
abundant,  and  is  followed  by  a  cessation  of  the  fetal  movements, 
diminished  size  of  the  abdomen,  flaccid  breasts,  a  sense  of  coldness  in 
the  hypogastrium,  uterine  contractions  or  pains,  and  expulsion  of  the 
fetus.  If  the  fetus  is  dead,  or  the  liquor  amnii  has  been  discharged, 
abortion  will  almost  certainly  take  place,  sooner  or  later,  though  no 
time  can  be  positively  determined  after  the  death  of  the  fetus,  for  its 
expulsion. 

Between  dysmenorrhea  and  abortion  there  is  considerable  resem- 
blance in  the  character  as  well  as  the  seat  of  the  pains;  both  are 
intermittent,  and  both  cease  after  expulsion  of  the  uterine  contents; 
hence,  it  becomes  the  accoucheur  to  proceed  cautiously  in  forming  his 
diagnosis.  He  must  first  endeavor  to  ascertain  whether  pregnancy 
has.  taken  place ;  failing  in  this,  he  must  inquire  into  the  character  of 
the  previous  menstruations,  whether  they  were  painful,  accompanied 
with  much  hemorrhage,  etc.  And  he  should  never  fail  to  examine  all 
the  discharges,  especially  the  clots,  if  they  have  not  been  thrown  away, 
breaking  them  down  between  the  fingers,  and  among  which  he  may 
discover  the  entire  ovum,  or  only  a  portion  of  it;  indeed  he  should 
require  the  nurse  to  save  all  the  discharges  during  the  progress  of  the 
abortion,  that  he  may,  by  this  examination,  not  have  a  clot  of  blood 
mistaken  for  the  ovum,  and  every  practitioner  should  perfect  himself 
in  a  knowledge  of  this  kind,  not  only  by  an  examination  whenever 
the  opportunity  occurs,  but  also  by  procuring,  if  possible,  ten  or 
twelve  specimens  of  ova  at  various  periods  of  pregnancy,  and  preserv- 
ing them,  so  as  to  accustom  the  eye  to  a  familiarity  with  them;  though 
it  must  not  be  forgotten,  that  the  ovum  may  pass  away  without  having 
been  observed,  or  even  be  discharged  in  minute  portions  with  the 
sanguineous  discharge,  more  or  less  hemorrhage  continuing  for  some 


•jr>4  KING'S  ECLECTIC  OBSTETRICS. 

time  subsequently.  If  he  ascertains  that  the  former  menstruations 
were  healthy,  and  that  between  the  present  difficulty  and  the  last 
menstruation,  one  or  two  months  have  been  passed  without  any  dis- 
charge, these  are  strong  grounds  for  suspecting  abortion;  if  pregnancy 
e\i.-ts,  abortion  is  undoubtedly  in  progress.  The  blood  in  dysmen- 
orrhea  is  menstruous,  while  that  in  abortion  is  sanguineous,  and 
escapes  in  larger  quantities  than  is  usual  to  the  catamenia.  The  finger 
should  likewise  be  introduced  into  the  vagina  for  the  purpose  of  ascer- 
taining the  condition  of  the  cervix,  and  if  it  be  found  shorter  than 
normal,  its  orifice  patulous  and  sufficiently  dilated  to  admit  the  end 
of  the  finger,  and  especially  if  during  a  pain,  the  membranes  are 
found  tense  and  protruding,  the  diagnosis  becomes  more  certain. 

The  diagnosis  of  abortion  is  more  positive  as  the  period  of  utero- 
gestation  advances,  because  the  development  of  the  uterus  can  then  be 
readily  ascertained,  the  pains  will  be  more  violent,  the  hemorrhage 
more  abundant,  and  the  dilatation  of  the  os  uteri  more  easily  detected. 
After  the  fifth  month  the  death  of  the  fetus  may  also  be  more  posi- 
tively ascertained  by  auscultation,  which  will  fail  to  detect  the  sounds 
of  the  fetal  heart,  and  if  it  has  been  dead  for  a  few  days,  there  will  be 
found  an  emaciation  and  flaccidity  of  the  breasts,  a  diminution  in 
volume  of  the  abdomen,  with  weight  in  the  hypogastrium,  dragging 
sensations  about  the  loins,  and  cessation  of  the  fetal  motions  which 
were  previously  observed  by  the  female.  In  the  early  months  of 
pregnancy,  if  nausea,  vomiting,  or  other  sympathetic  irritations  con- 
nected with  this  condition,  and  which  are  present  with  a  patient, 
beqome  suddenly  suspended,  it  affords  grounds  for  suspicion  of  ap- 
proaching abortion. 

The  prognosis  of  abortion  varies  according  to  its  cause,  as  well  as 
the  period  in  which  it  occurs;  females  who  abort  are  always  exposed 
to  more  danger  than  when  delivery  takes  place  naturally  at  full  term. 
In  a  few  cases,  death  takes  place  during  the  accident,  but  more  com- 
monly no  immediate  fatal  effects  happen,  though  they  are  very  apt  to 
ensue  as  secondary  results,  being  the  consequence  of  some  chronic 
disease  of  the  uterus,  ovaries,  etc.,  produced  by  the  abortion.  Females 
at  full  term  are  more  subject  to  acute  maladies,  which  often  prove 
immediately  fatal,  while  the  serious  results  of  abortion  more  commonly 
manifest  themselves  at  a  remote  period ;  yet  grave  consequences  may 
occur  speedily  under  either  of  these  conditions.  Abortion  is  very 
generally  unfavorable  to  the  fetus,  because  its  expulsion  happens 
during  its  stage  of  non-viability,  and  its  death  must  inevitably  take 


HEMORRHAGE    AND    ABORTION.  255 

place;  or,  the  abortion  may  have  been  determined  by  its  death.  In 
this  latter  ease,  the  fetus,  acting  as  a  foreign  body,  excites  the  uterus 
to  contractions :  but  this  eifect  may  not  take  place  for  weeks  and  even 
months  after  its  death. 

Abortion  occurs  with  more  difficulty,  and  is  attended  with  more 
danger,  after  the  second  month  of  pregnancy  than  before,  on  account 
of  the  increased  size  of  the  ovum,  and  the  unfavorable  condition  of 
the  cervix  to  dilatation;  and  the  more  advanced  the  pregnancy,  the 
greater  is  the  danger  from  hemorrhage.  Probably,  abortions  occuring 
during  the  third  and  fourth  months  of  pregnancy,  are,  as  a  general 
rule,  more  dangerous  than  at  any  other  period.  If  the  hemorrhage  is 
profuse,  abortion  will  be  very  apt  to  follow,  though  the  practitioner 
must  bear  in  mind,  that  large  and  frequent  hemorrhages  may  occur, 
and  yet  pregnancy  continue  to  the  full  term.  If  the  pains  occur  at 
regular  intervals,  with  dilatation  of  the  os  uteri,  and  protrusion  of 
the  membranes,  the  abortion  almost  always  follows ;  and  if  the  mem- 
branes be  ruptured,  it  will  certainly  occur;  though  I  know  of  one  in- 
stance in  which,  in  order  to  effect  an  abortion,  the  membranes  had 
been  perforated,  and  a  large  amount  of  fluid  (liquor  amnii)  escaped, 
and  yet  the  woman  went  to  full  term  with  a  living  fetus.  The  death 
of  the  fetus  will  likewise  positively  determine  it,  though  a  few  in- 
stances are  related  of  an  opposite  character. 

If  the  abortion  be  produced  by  constitutional,  accidental  or  mechan- 
ical causes,  it  is  usually  more  violent  or  alarming  in  its  results,  than 
when  owing  to  the  uterine  or  ovuline.  When  it  occurs  during  acute 
attacks,  as  measles,  erysipelas,  scarlatina,  small-pox,  typhus,  etc.,  being 
the  result  of  the  severity  of  the  attack,  it  is  very  apt  to  prove  fatal, 
especially  when  it  takes  place  before  a  mitigation  or  cure  of  the  acute 
disease  has  been  effected.  When  produced  mechanically,  the  principal 
danger  is  from  hemorrhage,  peritonitis,  or  metritis.  Usually,  the  more 
slowly  the  abortion  comes  on,  the  less  danger  is  there  to  fear  from 
hemorrhage,  though  the  constitutional  effects  are  more  to  be  dreaded, 
than  when  it  is  accomplished  with  rapidity.  Previous  abortions 
always  exert  an  unfavorable  influence  upon  subsequent  pregnancies, 
predispo'sing  to  a  similar  accident,  and  which,  of  course,  requires  the 
especial  attention  of  the  practitioner. 

The  ovum,  in  an  abortion  previous  to  the  third  month,  is  usually 
expelled  entire,  but  after  this  period  it  commonly  proceeds  as  at  full 
term,  the  liquor  arnnii  being  first  discharged,  followed  by  the  embryo, 
and  sooner  or  later  by  the  placenta.  At  the  third  and  fourth  months. 


256  KING'S  ECLECTIC  OBSTETRICS. 

the  placenta  has  considerably  augmented  in  size,  and  has  likewise 
formed  close  adhesions  with  the  uterus ;  and  this  latter  organ,  though 
it  may  have  acquired  a  degree  of  contractile  power  sufficient  to  expel 
the  ovum,  does  not  possess  the  contractility  of  tissue  as  developed  at 
full  term,  and  is  frequently  incapable  of  overcoming  the  attachment 
existing  between  it  and  the  placenta.  In  an  abortion  at  this  period,  a 
partial  evacuation  of  the  uterine  contents,  is  very  apt  to  be  followed 
by  a  closure  of  the  os  uteri,  and  a  cessation  of  the  symptoms,  leading 
the  practitioner  to  believe  that  the  abortion  has  happily  terminated ; 
but  after  several  days  the  hemorrhage,  generally  preceded  and  accom- 
panied with  pains,  again  appears  with  increased  severity,  and  if  the 
cause  be  not  removed,  the  patient  dies.  The  cause,  in  this  instance, 
is  a  retained  placenta  and  membranes;  the  utero-placental  adhesions 
having  been  overcome,  hemorrhage,  and  sometimes  copious  hemor- 
rhage, follows  the  separation  of  the  placenta  from  the  uterus,  which 
remains  detached  in  the  uterine  cavity,  irritating  the  uterus  and  pre- 
venting its  complete  contraction,  thereby  promoting  an  increased 
hemorrhage,  and  causing  a  fatal  termination,  if  the  patient  be  not 
relieved  by  art.  And  whenever  hemorrhage  occurs,  several  days 
subsequent  to  an  abortion,  the  practitioner  should  always  suspect  the 
presence  of  the  placenta  and  membranes  within  the  uterus,  without 
regard  to  the  statements  that  may  be  made  to  him,  affirming  that  these 
have  been  expelled.  He  should  at  once  make  a  vaginal  examination, 
when  he  will  probably  find  a  partially  dilated  os  uteri,  with  a  portion 
of  the  placenta  protruding.  Should  the  placenta  be  only  partially 
detached,  the  os  may  be  slightly  dilated,  but  without  protrusion  of  the 
placenta,  depending  however  upon  its  situation  and  extent  of  separa- 
tion. Occasionally,  the  placenta  decomposes,  the  uterine  discharges 
become  fetid,  absorption  of  the  putrid  matter  takes  place,  and  an 
irritative  fever  ensues,  requiring  all  the  skill  of  the  practitioner  to 
overcome,  or  to  avert  its  fatal  eifects.  Putrefaction  of  the  dead  fetus 
takes  place  only  when  the  membranes  are  ruptured,  which  admits  the 
air  into  the  cavity  of  the  uterus ;  decomposition  without  putrefaction 
ensues  when  the  membranes  are  entire.  Absorption  of  the  placenta 
has  been  observed,  both  after  an  abortion,  as  well  as  after  a 'natural 
accouchement.  Sometimes  an  effusion  of  blood  into  the  placenta  may 
occur,  and  by  imparting  to  it  a  kind  of  organization,  produce  wha< 
are  known  as  "  fleshy  moles." 

The  TREATMENT  varies  according  to  the  symptoms  which  are 
presented  the  principal  indications  being,  to  prevent  the  abortion  if 


HEMORRHAGE    AND    ABORTION.  257 

possible,  and  when  this  can  not  be  effected,  to  assist  the  expulsion  of 
the  uterine  contents,  and  likewise  to  remedy  any  subsequent  accidents. 
When  the  pains  are  somewhat  continuous,  and  are  experienced  pre- 
vious to  the  hemorrhage  which  considerably  mitigates  their  severity, 
the  case  is  very  probably  one  of  uterine  congestion;  but  when  the 
hemorrhage  is  observed  first,  followed  by  pains  increasing  in  severity 
and  with  well  marked  remissions,  abortion  is  about  to  ensue.  In  all 
cases  of  abortion,  the  practitioner  should  carefully  examine  the  con- 
dition of  the  cervix,  except  in  instances  where  the  death  of  the  fetus 
has  been  positively  ascertained;  if  it  be  of  normal  length  nud  thick- 
ness, but  slightly  dilated,  unfavorable  to  the  speedy  expulsion  of  the 
ovum,  and  if  the  hemorrhage  be  not  too  threatening,  an  attempt  may 
be  made  to  check  its  farther  progress;  but  if  it  be  dilated,  short,  the 
os  patulous,  and  attended  with  considerable  hemorrhage,  means  must 
be  adopted  wrhich  will  favor  the  speedy  expulsion  of  the  uterine  con- 
tents. And  in  making  this  examination,  no  roughness  or  violence 
must  be  used«,  lest  the  symptoms  of  the  abortion  be  aggravated. 

In  a  great  number  of  cases,  whether  abortion  ensues  or  not,  all  the 
treatment  required  will  be,  rest  in  the  recumbent  position,  a  cool, 
hard  bed,  perfect  quiet,  avoidance  of  stimulants,  and  all  excitement, 
quieting  of  nervous  fears  or  anxieties,  cooling  drinks  and  light  diet, 
with  an  occasional  dose  of  the  compound  powder  of  Ipecacuanha  and 
Opium,  say  four  or  five  grains  repeated  every  two,  three,  or  four 
hours,  for  the  purpose  of  subduing  the  pains.  It  is  claimed  by  the 
most  recent  writers,  that  to  arrest  uterine  action,  nothing  can  be  com- 
pared with  Opium ;  it  is  recommended  in  half-grain  doses,  repeated 
in  thirty  minutes,  if  necessary,  to  allay  uterine  excitation  and  control 
the  pains.  Laudanum  may  be  used;  a  drachm  in  starch-water 
enema.  But  where  this  course  does  not  speedily  effect  a  mitiga- 
tion of  the  symptoms,  there  having  been  no  escape  of  the  liquor 
amnii,  Viburnum  Prunifolium  should  be  given;  one  or  two 
•drachms  to  four  ounces  of  water,  in  teaspoo^ful  doses,  will  usually 
prove  efficient.  A  blister  applied  to  the  sacrum  was  formerly 
much  in  use;  it  will  likely  prove  beneficial  in  some  cases,  and  should 
be  tested  where  other  means  fail.  Should  any  displacement  of  the 
uterus,  or  other  affection  exist,  it  must  be  treated  as  heretofore  advised. 
Nauseating  with  a  preparation  composed  of  three  or  four  parts  of  the 
tincture  of  Lobelia,  and  one  of  the  tincture  of  Opium,  has  been  rec- 
ommended and  successfully  employed  in  some  cases,  but  I  deem  it 
inferior  to  the  means  above  named;  although  it  may  be  used,  should 
17 


•_'.">>  KING'S  ECLECTIC  OBSTETRICS. 

that  fail.  Care  is  required  not  to  cause  emesis,  which  might  render 
the  abortion  inevitable.  The  administration  of  Stramonium  seed  has 
been  highly  spoken  of,  but  I  have  never  seen  its  action  in  such 
cases,  and  can,  therefore,  say  but  little  about.it.  Tincture  of  Cannabis 
Indica,  in  doses  of  five  or  six  drops  every  one,  two,  four  or  six  hours, 
has  also  been  advised  as  an  anodyne  as  well  as  to  arrest  the  sanguin- 
eous discharge.  If  the  hemorrhage  be  slight,  it  may  not  require  any 
special  attention,  but  when  it  is  considerable,  effort  should  be  made  to 
check  it.  For  this  purpose,  cloths  wet  in  cold  vinegar  and  water,  or 
ice  applied  to  the  hyp9gastrium  and  pudendum  has  been  recommended; 
but  the  application  of  ice  within  the  vagina,  or  cold  vaginal  injec- 
tions, recommended  by  some  authors,  should  be  used  with  great 
caution,  lest  they  produce  the  accident  we  are  attempting  to  avert. 
Injections  of  water  as  hot  as  can  be  endured,  will  give  better  results, 
and  affect  the  patient  more  pleasantly.  In  cpnnection  with  these,  in- 
ternal means  may  be  used,  a  few  drops  of  the  oil  of  Erigerou,  or  oil  of 
Erechthites  may  be  given,  in  mucilage  or  on  sugar,  eve»y  ten,  thirty, 
or  sixty  minutes,  according  to  the  severity  of  the  hemorrhage ;  or  a 
powder  composed  of  burnt  Alum  and  Sulphate  of  Iron,  three  grains, 
Capsicum,  one  grain,  may  be  administered  as  often  as  the  urgency  of 
the  symptoms  demand;  the  burnt  Alum  and  Sulphate  of  Iron  form  a 
valuable  hemostatic,  and  may  be  made  by  mixing  together  two  parts 
of  Sulphate  of  Iron  and  one  of  Alum,  and  exposing  them  to  heat  in  a 
stone  or  clay  dish,  until  the  mixture  assumes  a  reddish  color.  Other 
astringents  may  be  employed  in  the  absence  of  those  named,  as  Tan- 
nin, Hamamelis,  Gallic  Acid,  etc.  An  agent  in  common  use  as  a 
hemostatic  is  powdered  Alum  and  Nutmegs;  the  late  Prof.  Meigs 
recommended  it  in  the  proportion  of  five  grains  of  the  former  to  one 
of  the  latter  as  a  dose,  to  be  repeated  every  half-hour  or  hour.  It 
will  frequently  be  found  that  internal  remedies  derange  the  digestive 
organs  and  occasion  constipation,  without  everting  any  influence  what- 
ever upon  the  hemorrhage ;  in  such  instances  a  soft  sponge,  or  plug 
of  cotton  wadding  moistened  with  solution  of  Alum,  Tannin,  or  Per- 
chloride  of  Iron,  and  introduced  within  the  vagina  so  as  to  slightly 
press  against  the  os,  will  promote  coagulation  and  tend  to  arrest  the 
flow;  and  this  application  may  be  worn  for  several  hours  at  a  time, 
changing  it  only  as  required.  I  regard  the  solution  of  Perchloride 
of  Iron,  as  just  mentioned,  as  one  of  the  most  reliable  agents  at  our 
command,  in  controlling  uterine  hemorrhage,  and  have  frequently 
gotten  prompt  results  from  it,  after  other  means  have  failed.  It  may 


HEMORRHAGE    AND    ABORTION.  259 

be  used  on  absorbent  cotton,  after  which  all  coagula  resulting 
therefrom  should  be  removed  by  hot  water  vaginal  injections. 
A  rectal  enema,  composed  of  Lloyd's  Ergot,  two  fluid  drachms, 
thin  Starch  solution,  one  fluid  ounce,  retained  in  the  rectum  for  an 
hour,  repeating  it  two  or  three  times  a  day,  if  necessary,  has  proved 
successful  in  some  instances  in  arresting  the  pains  and  checking  the 
hemorrhage.  It  is  not  required  that  the  patient  should  be  confined 
to  the  recumbent  posture  for  more  than  the  first  two  or  three  days, 
and,  subsequently,  even  though  some  flow  be  present,  only  occasion- 
ally, according  to  the  symptoms;  a  constant  lying  in  bed  will  affect 
the  general  health,  occasion  anorexia  and  nervous  excitement,  and 
rather  tend  to  facilitate  instead  of  prevent  the  abortion.  On  the 
other  hand,  should  there  exist  any  congestion  or  irritability  of  the 
uterus,  an  erect  position,  or  any  bodily  movements,  increase  the 
liability  to  abort,  hence,  these  conditions  must  be  removed  before 
allowing  the  female  to  move  about. 

Should  these  means  fail  to  arrest  the  hemorrhage,  and  there  is  no 
doubt  in  the  mind  of  the  practitioner  but  that  the  expulsion  of  the 
ovum  must  take  place — is  inevitable — the  tampon  or  plug  should  be 
employed.  This  consists  of  pieces  of  linen  cloth,  muslin,  silk,  or 
balls  of  absorbent  cotton.  The  tampon  can,  as  a  rule,  be  best  applied 
by  using  Sims'  speculum.  It  is  always  well  to  wash  the  vagina  out 
with  hot  water;  then,  if  the  cotton  is  used,  the  balls  may  be  carried 
to  the  parts  by  means  of  dressing-forceps,  firmly  packing  them  around 
the  cervix.  The  first  few  balls  should  be  sprinkled  with  lodoform. 
If  muslin  is  used,  the  pieces  should  be  about,  three  or  four  inches 
square,  which  are  separately  introduced  into  the  vagina,  until  it  is 
completely  filled  and  distended;  these  are  to  be  kept  in  place  by  a 
napkin  or  bandage,  and  may  be  allowed  to  remain  for  six  or  twelve 
hours,  but  never  to  exceed  twenty-four.  Sometimes  sponge  is  used, 
but  I  think  it  inferior  to  the  pieces  just  referred  to.  The  first  piece 
introduced  may  be  medicated  with  Tannin,  Alum,  or  other  astringent, 
and  the  remaining  pieces  forming  the  tampon  should  be  moistened 
with  Carbolized  Oil,  to  admit  of  their  ready  removal,  and  to  act  as  an 
antiseptic.  It  must  be  especially  borne  in  mind  by  the  practitioner, 
that  the  tampon  is  never,  under  any  circumstances,  to  be  used  after 
the  fifth  month  of  pregnancy ;  because,  the  uterine  capacity  having 
become  much  augmented,  its  cavity  may  become  distended  with 
blood  or  coagula,  and  cause  a  fatal  result.  Previous  to  the  fifth 
month,  however,  it  is  incapable  of  containing  an  amount  of  blood 


260  KING'S  ECLECTIC  OHSTHTKICS. 

sufficient  to  prove  fatal  from  a  concealed  hemorrhage.  Upon  the  re- 
moval of  the  tampon,  a  roagulum  may  be  observed  attached  to  its 
upper  part,  in  the  center  of  which  the  ovum,  or  its  remains,  will  gen- 
erally be  found.  Cotton-wool  was  regarded  by  J.  Marion  Sims  as 
the  best  material  from  which  to  prepare  a  tampon.  He  advises  that 
it  be  soaked  in  some  .antiseptic  solution  and  then  molded  into  small 
disks;  they  are  now  carried  high  up,  with  the  dressing-forceps,  and 
packed  tightly  around  the  intra-vaginal  portion  of  the  cervix,  and  so 
on  until  the  vagina  is  filled.  This  makes,  probably,  the  most  solid 
tampon  that  can  be  used.  When  the  tampon  is  removed,  after 
about  twelve  hours,  the  parts  should  be  carefully  examined,  and,  in 
case  the  cervix  is  not  sufficiently  dilated  to  allow  the  ovum  to  pass, 
then  at  once  re-apply  the  tampon  as  in  the  beginning,  and  so  continue 
until  dilatation  follows.  The  tampon  not  only  acts  as  a  mechanical 
agent  in  controlling  the  hemorrhage,  but  hastens  the  expulsion  of  the 
ovum  by  exciting  contractions  of  the  uterus.  Ergot  is  usually  indi- 
cated in  cases  requiring  the  tampon;  and  when  associated  they  act 
very  well.  The  ovum,  as  a  rule,  is  expelled  entire  in  cases  where  this 
treatment  is  used.  Should  the  presence  of  the  tampon  induce  dysury, 
the  bladder  must  be  evacuated  by  means  of  a  catheter ;  and  during 
the  whole  treatment  the  female  should  be  kept  in  the  recumbent  posi- 
tion, and  not  allowed  to  arise  until  all  danger  from  hemorrhage  is 
over.  The  tampon  ought  never  to  be  used  when  there  is  any  pos- 
sibility of  checking  the  abortion,  as  it  is  very  apt  to  increase  the  ten- 
dency to  abort,  in  consequence  of  the  irritation  of  the  cervix  produced 
by  its  presence  having  extended  to  the  fundus ;  beside,  the  external 
discharge  of  blood  being  suppressed,  it  continues  to  be  effused  inter- 
nally, gradually  separating  the  ovum  from  the  uterus,  until  it  finally 
passes  off,  surrounded  with  a  compressed  coagulum.  Neither  should 
it  be  employed  after  the  expulsion  of  the  ovum,  nor  when  the  os  uteri 
has  dilated  to  an  extent  that  will  admit  a  finger  to  pass  and  remove 
the  embryo. 

Females  who  habitually  abort  in  the  early  months  of  pregnancy, 
should,  after  the  symptoms  of  abortion  have  been  removed,  be  advised 
to  remain  most  of  the  time  in  the  horizontal  position,  avoiding  all 
fatigue  and  violent  exertion,  until  the  uterus  has  risen  above  .the 
superior  strait  of  the  pelvis.  The  employment  of  the  lancet,  in  cases 
of  abortion,  is  recommended  by  some  authors,  but  I  can  not  perceive 
its  utility  ;  the  detachment  of  the  placenta  from  the  uterine  wall,  which 
is  the  cause  of  the  hemorrhage,  can  not  certainly  be  remedied  by  a 


HEMORRHAGE    AND    ABORTION.  261 

loss  of  blood  from  some  other  part  of  the  system,  for  in  all  the  cases 
which  I  have  witnessed  treated  by  blood-letting,  the  separation  con- 
tinued to  progress,  with  augmented  hemorrhage,  and  the  only  result 
gained  was  a  degree  of  debility  and  disposition  to  disease,  on  the  part 
of  the  female,  probably  greater  than  would  have  resulted  had  the  use 
of  the  lancet  been  omitted.  It  is  true,  that  in  consequence  of  the 
prostration  of  nervous  and  muscular  force  effected  by  its  use,  it  may 
overcome  rigidity  of  the  cervix,  and  favor  the  dilatation  of  the  os  uteri, 
when  the  fulfillment  of  these  indications  is  desired;  but  then  we  have 
remedies  which  produce  the  same  results  without  disposing  a  part  or 
all  of  the  constitution  to  any  of  the  after  disastrous  consequences  so 
common  to  blood-letting;  as  Lobelia,  and  still  better,  the  tincture  of 
Gelsemium,  from  the  relaxing  influences  of  either  of  which  the  patient 
will  speedily  recover.  I  am  aware  that  bleeding,  in  many  cases,  may 
arrest  or  modify  the  expulsive  contractility  of  the  uterus,  but  it  is  ef- 
fected at  a  great  expense  to  the  constitution  of  the  patient,  and  is  by 
no  means  a  safe  or  desirable  method  of  treatment;  Opium,  either  alone 
or  combined  with  Lobelia  or  Gelsemium,  will  not  only  produce  the 
same  results,  but  will  succeed  in  cases  where  bleeding  fails.  As  to 
bleeding  for  the  relief  of  plethora,  or  of  a  congested  condition  of  the 
uterus,  the  hemorrhage  undoubtedly  affords  all  the  benefit  that  can  be 
had  from  venesection,  especially  in  the  latter  condition;  and  the  ordi- 
nary means  advised  for  overcoming  or  relieving  either  of  these  states 
will  be  found  fully  efficient  without  a  resort  to  the  lancet — though  the 
lancet  saves  time  and  labor,  to  the  physician.  For  the  purpose  of 
equalizing  the  circulation,  it  has  been  advised  by  some  accoucheurs  to 
bathe  the  lower  extremities  of  the  female  in  warm  water;  with  some 
patients  this  course  may  be  attended  with  benefit,  but  it  should  always 
be  employed  with  caution,  as  among  many  women  it  will  be  found  to 
facilitate  the  abortion ;  it  is  only  in  hemorrhage  after  the  expulsion 
of  the  ovum  where  much  advantage  will  be  derived  from  this  local 
bathing. 

If  by  the  means  employed  the  abortion  is  not  prevented,  or  if  it  be 
so  far  advanced  that  no  hope  for  checking  it  can  be  reasonably  enter- 
tained ;  the  pains  increasing  together  with  the  hemorrhage,  the  os  uteri 
gradually  dilating,  and  the  ovum  being  within  reach  of  the  finger,  all 
that  the  practitioner  can  do  is  to  patiently  await  the  efforts  of  nature, 
and  carefully  watch  and  treat  the  hemorrhage ;  as  a  general  rule,  any 
artificial  interference  is  highly  improper,  and  might  give  rise  to  serious 
consequences.  The  practitioner  must  be  very  careful  not  to  rupture 


262  KING'S  ECLECTIC  OBSTETRICS. 

the  membranes  in  the  early  months,  for  the  purpose  of  facilitating 
expulsion,  as  it  is  always  desirable  that  the  ovum  be  expelled  entire, 
for  when  the  membranes  are  retained  after  the  discharge  of  the  fetus, 
there  is  danger  from  hemorrhage;  and  when,  in  cases  of  such  reten- 
tion, it  is  found  that  the  contractions  of  the  uterus  are  insufficient  to 
separate  and  expel  the  membranes,  the  os  being  sufficiently  dilated, 
agents  may  be  administered  which  will  promote  these  contractions,  as 
Ergot,  Macrotys,  Pulsatilla,  or  Quinine.  Creed's  method  will  often 
stimulate  the  uterus  to  increased  -action.  Agents  of  this  class  are  not 
to  be  depended  on  when  the  hemorrhage  is  alarming,  but  give  way  to 
more  radical  treatment,  as  will  be  presently  noticed.  The  fresh  inner 
bark  of  Cotton  root,  in  strong  infusion,  will  generally  excite  the  uterus 
to  energetic  action  ;  but  this  agent  can  rarely  be  had.  So  will  pow- 
dered or  grated  Nutmeg  in  teaspoonful  doses;  also  a  combination  of 
Borax  and  Cinnamon.  If  this  does  not  produce  the  desired  effect,  and 
the  hemorrhage  continues  unabated,  it  will  be  proper  for  the  practitioner 
to  introduce  a  finger  within  the  canal  of  the  cervix,  as  far  as  possible, 
then  bend  it  so  as  to  resemble  a  blunt  hook,  and  in  this  way  remove  the 
membranes,  and  in  doing  this  it  may  become  necessary  to  introduce  the 
whole  hand  into  the  vagina ;  or  a  wire  blunt-hook,  which  will  admirably 
answer  the  purpose,  may  be  made,  by  bending  a  piece  of  fine  wire  so  as 
to  form  two  parallel  strips  nearly  in  contact  with  each  other,  the  curved 
end  of  which  is  to  be  again  bent  so  as  to  .form  a  hook;  this  may  be 
introduced  into  the  uterus,  whenever  hemorrhage  is  owing  to  retained 
membranes,  for  the  purpose  of  removing  them.  Other  instruments 
have  likewise  been  recommended  for  this  purpose,  as  Bond's  placental 
forceps,  and  Dewees'  placental  hook.  But  in  the  introduction  of  the 
finger,  or  any  of  these  instruments  into  the  canal  of  the  cervix,  no 
force  must  be  employed,  too  much  care  and  gentleness  can  not  be 
observed;  no  attempts  whatever  should  be  made,  to  effect  dilatation, 
nor  should  these  means  be  employed  at  all  until  the  cervical  canal  has 
become  cylindrical  and  sufficiently  open  for  their  free  intromission. 
And  as  the  development  of  the  uterus  previous  to  the  fifth  month  is 
not  such  as  to  warrant  any  fears  of  a  serious  internal  hemorrhage,  the 
tampon  may  be  used,  in  conjunction  with  the  other  means,  to  check 
flooding,  if  circumstances  prevent  the  removal  of  the  membranes. 
The  introduction  of  the  tampon  is  sometimes  attended  with  such  dis- 
agreeable and  painful  sensations  that  the  patient  can  not  endure  its 
presence  for  even  ten  minutes ;  in  such  cases,  as  well  as  in  cases  wrhere 
it  does  not  check  the  hemorrhage,  the  evacuation  of  the  uterine  con- 
tents must  be  promoted  as  soon  as  possible.  It  may  be  proper  to 


HEMORRHAGE    AND    ABORTION.  263 

remark  here,  that  when  the  hemorrhage  is  such  as  to  threaten  the  life 
of  the  mother,  every  means  must  be  employed  to  arrest  it,  even  should 
the  means  effect  the  death  and  expulsion  of  the  fetus,  as  the  safety  of 
the  mother  always  demands  s-uch  sacrifice.  When  the  death  of  the 
fetus  has  occasioned  the  abortion  the  hemorrhage  is  not  generally 
excessive. 

A  very  good  rule  to  govern  one's  actions  in  cases  of  hemorrhage 
from  abortion  is,  after  deciding  it  to  be  inevitable,to  use  the  tampon 
as  has  been  suggested,  in  cases  where  there  is  no  dilatation  of  the  cer- 
vix, and  so  continue  together  with  the  administration  of  Ergot,  until 
dilatation  is  produced.  .Should  the  hemorrhage  be  alarming,  and  the 
cervix  already  fully  dilated  and  relaxed,  then  forcibly  remove  the  ovum 
by  introducing  the  fingers  or  hand. 

In  the  more  advanced  stage  of  pregnancy,  when  in  consequence  of 
excessive  hemorrhage  or  other  cause  it  becomes  necessary  to  facilitate 
the  expulsion  of  the  fetus,  the  membranes  may  frequently  be  ruptured 
with  advantage,  because  at  this  period,  the  uterus  has  increased  in  size 
sufficiently  to  receive  two  or  three  fingers,  or  even  the  whole  hand, 
should  it  become  necessary  to  remove  a  retained  placenta.  And  the 
extraction  of  the  placenta  should  always  be  effected,  when  the  abortion 
occurs  at  .a  period  of  utero-gestation,  in  which  the  uterus  will  permit 
the  introduction  of  the  hand  within  its  cavity.  Other  means  may 
likewise  be  employed  to  favor  the  expulsion,  as  Ergot,  Macrotys,  in- 
jections of  hot  water  together  with  Creed's  method.  Cold  applications 
may  be  made  to  the  pubes  and  hypogastrium,  to  aid  in  arresting1  the 
hemorrhage.  At  this  period  I  usually  prefer  as  an  internal  hemostatic, 
the  tincture  of  Cinnamon,  of  which  from  half  a  fluid  drachm  to  a 
fluid  drachm  may  be  given  every  ten,  thirty  or  sixty  minutes,  as  the 
urgency  of  the  case  requires,  in  a  wine-glass  of  sweetened  water;  ten 
or  fifteen  drops  of  Laudanum  or  Viburnum  may  be  added  to  each  dose, 
in  case  the  pains  are  very  severe.  The  Cinnamon  and  Ergot  may  be 
administered  together  in  doses  of  from  fifteen  to  thirty  drops  of  each; 
the  combination  of  the  two  agents  exhibit  more  striking  haemostatic 
properties  than  either  administered  singly.  After  the  embryo  and  its 
membranes  have  passed  away  from  the  uterus,  should  hemorrhage  still 
continue,  it  must  be  treated  in  the  same  manner  as  recommended  for 
flooding  after  delivery  at  full  term.  Intra-uterine  washings  of  a  solu- 
tion of  Iodine  after  the  evacuation  of  the  contents,  have  been  advised 
both  for  its  antiseptic  and  haemostatic  effect. 

A  weak  solution  of  Sulphuric  Acid  has  been  frequently  employed  in 
hemorrhages  occurring  during  pregnancy,  as  well  as  after  delivery, 


264  KING'S  ECLECTIC  OBSTETRICS. 

with  decided  benefit.  It  is  exhibited  as  a  vaginal  enema,  ten  or  fifteen 
drops  of  the  acid  being  added  to  three  or  four  ounces  of  warm  water. 
Care  should  be  taken,  however,  not  to  employ  it  when  it  is  desired  to 
check  the  abortion.  Many  persons  use  this  injection  with  the  criminal 
intention  of  procuring  an  abortion. 

In  cases  of  excessive  hemorrhage  occurring  several  days  after  the 
abortion  has  apparently  terminated,  and  which,  as  previously  stated, 
are  owing  to  a  retention  of  the  placenta  and  membrane,  the  wire 
blunt-hook  may  be  slowly  and  carefully  passed  within  the  canal  of 
the  cervix,  and  the  membranes  extracted  by  means  of  a  gentle  manip- 
ulation;  if  this  can  not  be  accomplished,  the  practitioner  will  most 
likely  have  to  contend  with  the  effects  of  putrefactive  absorption. 
The  patient  with  whom  there  is  a  retention  of  the  placenta  is  exposed 
to  hemorrhage,  to  septicaemia,  to  hydatoid  degeneration  of  the  placenta, 
or  to  polypoid  growths  of  which  the  placenta  forms  the  nucleus ; 
hence  the  necessity  for  not  allowing  it  to  remain  too  long  within  the 
uterus,  and  especially  when  the  flow  is  continuous  or  excessive.  Putre- 
factive decomposition  may  be  known-  by  a  fetid  lochial  discharge,  and 
absorption  of  the  putrid  matter  gives  rise  to  an  irritative  fever  which 
may  prove  dangerous.  The  fever  must  be  treated  upon  general  prin- 
ciples, using  Aconite  or  Veratrum  as'  indicated,  and  being  careful  to 
support  the  strength  of  the  patient;  and  the  vagina  must  be  frequently 
syringed  with  water,  as  hot  as  the  patient  can  endure,  in  which  shall 
be  used  Borax,  Asepsin,  Carbolic  Acid,  Distillate  of  Hamamelis,  or 
Fluid  Hydrastis,  as  the  practitioner  may  prefer,  for  the  purpose  of 
removing  the  putrified  material  as  soon  as  it  forms;  and  for  the  pur- 
pose of  obviating  putridity  of  the  remaining  portions  of  the  placenta 
or  membranes,  soft  cotton  wool  has  been  recommended  moistened  with 
diluted  Carbolic  Acid,  or  other  antiseptic,  and  carefully  introduced 
within  the  canal  of  the  cervix,  (dilating  this,  if  necessary,  by  means 
of  tents),  removing  it  every  two  or  three  hours,  and  replacing  it  with 
a  new  pledget.  As  a  rule,  I  believe  pledgets  of  lint  should  not  be 
introduced  into  the  cervix  at  this  time,  as  it  might  be  an  obstruction 
to  the  free  drainage  of  the  uterus,  and  as  a  result  of  pent  up  purulency 
thwart  the  very  object  we  are  trying  to  accomplish.  Internally,  to 
lessen  the  dangers  from  septicaemia,  such  agents  as  Chlorate  of  Potash, 
Baptisia,  Phytolacca,  dilute  Nitro-Muriatic  Acid,  Asepsin  and  such 
other  remedies  as  would  tend  to  eliminate  the  poison  that  might  have 
been  absorbed  by  the  system  may  be  administered,  as  well  as  tonics, 
good  diet,  etc.,  as  indicated  from  time  to  time.  I  have  in  several  in- 
stances succeeded  in  preventing  any  serious  consequences  by  adminis- 


HEMORRHAGE    AND    ABORTION.  265 

tering,  in  connection  with  the  general  treatment,  Macrotys,  Pulsatilla, 
Phytolacca,  together  with  direct  sedatives,  if  there  happens  to  be  an 
increased  temperature,  as  Aconite,  Veratrum  or  small  doses  of  Digi- 
talis. The  Parturient  Balm  (Am.  Dispensatory)  as  a  uterine  tonic  is 
a  good  remedy,  especially  during  convalescence.  The  infusion  of  Digi- 
talis is  useful  in  some  cases.  Peruvian  bark  in  Port  wine  has  also 
been  used  in  a  few  cases  with  apparent  benefit,  where  a  tonic  in  called 
for. 

After  an  abortion,  especially  in  advanced  pregnancy,  it  may  become 
proper  to  apply  a  bandage  around  the  abdomen,  the  same  as  after  or- 
dinary labor,  and  the  patient  should  be  kept  for  a  few  days  in  a  state 
of  rest ;  if  there  be  much  exhaustion  from  loss  of  blood,  the  diet  must 
be  similar  to  that  recommended  in  uterine  hemorrhage,  or  flooding 
after  labor  at  full  term.  A  lochial  discharge,  as  well  as  secretion  of 
milk,  is  most  commonly  present,  after  abortion  in  the  advanced  stage 
of  gestation. 

The  sequelce,  or  after  consequences  of  abortion,  are  irritative  fever, 
metritis,  peritonitis,  phlebitis,  ulceration  of  the  cervix,  anemia,  leucor- 
rhea,  menorrhagia,  dysmenorrhea,  organic  disease  of  the  uterus, 
sterility,  or  phthisis,  either  of  which,  when  present,  will  require  the 
treatment  appropriate  to  such  abnormal  condition. 

When  an  abortion  has  once  taken  place,  it  is  very  liable  to  recur 
during  the  following  pregnancy,  and  to  prevent  the  occurrence  of 
which,  the  practitioner  should  endeavor  to  ascertain  its  cause,  and 
remove  it,  if  possible,  by  the  appropriate  treatment  pursued  during 
the  intervals  between  the  pregnancies,  as  well, as  during  pregnancy 
previous  to  the  manifestation  of  the  aborting  symptoms.  It  will  be 
still  more  efficacious,  however,  if  the  patient,  while  endeavoring  to 
become  cured  of  her  difficulty,  will  give  the  reproductive  organs  rest 
by  an  absolute  avoidance  of  sexual  excitement,  cohabitation,  and 
pregnancy,  for  a  considerable  length  of  time.  Should  it  be  owing  to 
tumors,  diseased  ovum,  or  other  intra-uterine  diseases,  internal  treat- 
ment will  be  of  little  avail ;  though  in  these  cases  the  internal  use  of 
alteratives,  uterine  tonics,  proper  diet,  exercise,  etc.,  may  be  adopted, 
with  a  faint  hope  that  good  may  follow.  If  a  fissured  os  and  cervix 
uteri  be  the  cause,  as  determined  by  a  careful  examination,  and  which 
is  often  present  in  those  cases  of  abortion  that  occur  successively  in 
the  same  woman  at  the  same  period  of  gestation,  the  fissures  must  be 
healed  by  local  applications  of  Nitric  Acid,  Nitrate  of  Silver,  Caustic 
Iodine,  or  Chromic  Acid,  etc.,  being  careful  to  apply  these  agents  in 


266  KING'S  ECLECTIC  OBSTETRICS. 

a  manner  that  will  not  destroy  the  tissues  of  the  parts;  at  the  same 
time  administering  such  agents  internally  as  may  be  indicated  to 
relieve  pain,  remove  anemia,  or  lessen  uterine  congestion,  etc.,  \vhen 
either  of  these  are  present.  The  trouble  being  a  slight  fissured  con- 
dition, it  may  often  be  cured,  or  at  least  benefited,  by  the  direct 
application  of  caustics;  if,  however,  the  cervix  should  be  deeply 
lacerated,- then  nothing  short  of  a  careful  operation,  known  as  traehe- 
lorraphy,  will  restore  the  parts  and  overcome  the  trouble.  It  is 
necessary  to  remove  all  cicatricial  tissue,  after  which  the  parts  may  be 
sutured  together.  Uterine  congestion,  as  a  cause  of  abortion,  requires 
an  avoidance  of  coition,  diuretics,  regularity  of  bowels,  moderate  diet 
and  exercise,  and  sometimes  warm  hip  baths.  If  the  uterus  be  dis- 
placed, it  must  be  restored  to  its  normal  position;  should  ulceration 
of  the  cervix  uteri  be  a  cause,  it  must  be  treated  by  applying  locally 
concentrated  Nitric  Acid  by  means  of  a  pine  stick  porte-caustic,  Xi- 
trate  of  Silver,  solution  of  Sesquicarbonate  of  Potassa,  solution  of 
Sulphate  of  Zinc,  etc.,  the  application  to  be  made  by  means  of  a  spec- 
ulum. The  patient  must  likewise  be  kept  in  a  state  of  rest,  and  if 
treated  during  pregnancy,  no  vaginal  injections  must  be  used.  Dys-r 
menorrhea  is  frequently  a  cause  of  abortion,  and  when  present,  the 
functions  of  the  uterine  system  must  be  attended  to,  administering 
uterine  tonics,  Chlorate  of  Potassa,  and  pursuing  the  means  generally 
recommended  in  Eclectic  teachings  to  remove  the  difficulty ;  and  so 
in  all  other  uterine  derangements.  In  those  cases  of  abortion  due  to 
an  enfeebled  condition  of  the  uterus,  to  a  premature  disintegration 
and  exfoliation  of  the  decidua,  or  to  morbid  nervous  excitability  of 
the  reproductive  system,  I  have  found  the  Helonias  Dioica,  Pulsatilla, 
Senecio  and  Macrotys  to  be  excellent  remedies,  in  combination  with 
Chlorate  of  Potassa;  and,  indeed,  have  even  found  it  efficacious  in 
geveral  instances  where  the  cause  of  the  abortion  was  quite  obscure; 
it  is  especially  required  in  all  these  instances  that  the  uterus  have  a 
long  period  of  rest.  If  the  abortion  is  owing  to  a  syphilitic  taint  of 
the  system,  this  must  be  remedied  by  the  usual  treatment  for  this  dis- 
ease, administered,  in  most  instances,  to  both  parents.  The  bowels 
must  be  kept  regular,  the  diet  must  be  nutritious,  avoiding  fats  and 
acids,  the  surface  of  the  body  must  be  frequently  bathed  with  a  weak 
alkaline  solution,  and  too  much  exercise  must  be  prohibited ;  if  the 
male  parent  is  contaminated  with  the  disease,  but  little  benefit  can  be 
expected  unless  he  is  also  placed  under  proper  treatment.  The  ad- 
ministration of  Mercury,  so  highly  recommended  by  some  authors,  is 


HEMORRHAGE    AXD    ABORTION.  267 

of  no  utility,  as  this  agent  will  not  only  effect  no  cure  of  the  disease, 
but  has  a  strong  tendency  to  destroy  the  vitality  of  the  fetus,  and  thus 
add  to  the  already  existing  cause  of  abortion.  Any  other  disease  with 
which  the  patient  may  be  affected,  whether  general  or  local,  must,  if 
possible,  be  eradicated  by  the  appropriate  remedies,  which  may  be 
employed  not  only  during  the  interval  between  pregnancy,  but  like- 
wise when  this  condition  is  present.  Fatty  degeneration  of  the  chorion 
and  placenta,  detected  by  careful  microscopic  investigation,  will  re- 
quire the  same  treatment  pursued  in  similar  degeneration  of  other 
organs.  Chlorate  of  Potash  has  been  recently  used,  with  marked 
success,  in  a  number  of  cases  where  women  habitually  aborted  owing 
to  degeneration  of  the  placenta,  and,  as  a  consequence,  faulty  nutrition 
of  the  fetus.  This^remedy,  when  further  tested,  will,  I  believe,  prove 
to  be  a  specific  in  this  diseased  condition  of  the  placenta. 

Ansemic  or  chlorotic  patients  should  be  treated  with  vegetable 
and  chalybeate  tonics,  among  which  I  prefer  Acid  Solution  of  Iron; 
those  who  are  plethoric  require  light  and  moderate  diet,  exercise,  reg- 
ularity of  bowels,  and  depletion  by  diuretics;  and  coition  should  be 
very  moderate  until  pregnancy  occurs,  during  which  it  must  be  pos- 
itively prohibited.  If  the  patient  resides  in  a  miasmatic  district, 
usually  so  called,  a  removal  will  in  many  instances  be  followed  with 
benefit ;  though  occasionally  the  internal  use  of  Sulphate  of  Quinine, 
Fowler's  solution  of  Arsenic,  or  dilute  Kitric  Acid,  will  be  found  to 
answer  an  excellent  purpose.  If  she  be  giving  suck  when  pregnancy 
occurs,  the  child  must  be  weaned;  if  there  be  any  vesical  or  rectal 
irritation,  hemorrhoids,  or  a  constipated  condition  of  the  bowels,  these 
may  be  overcome  by  an  attention  to  diet,  aided  by  laxatives,  anodyne 
and  mucilaginous  enemata,  quiet,  and  an  avoidance  of  all  active  med- 
icines. As  habitual  abortions  usually  occur  at  a  regular  period  of 
pregnancy,  the  patient  should  at  this  period  more  frequently  assume 
the  recumbent  position,  upon  a  hard  mattress,  in  a  cool  room,  and  be 
otherwise  treated  according  to  the  peculiarities  or  indications  of  her 
individual  case ;  and  which  treatment  should  be  perseveringly  pursued 
until  the  aborting  period  has  passed  by. 

When  habitual  abortion  obstinately  resists  our  endeavors  to  remove 
it,  it  will  ultimately  destroy  the  constitution  of  the  patient;  and  it 
therefore  becomes  necessary  on  her  part  to  pursue  a  rigid  and  self- 
denying  course.  The  indications  are:  firstly,  to  avoid  pregnancy, 
until  the  functions  of  the  reproductive  organs  have  been  restored  to  a 
normal  condition;  and,  secondly,  to  effect  this  restoration.  The  only 


2(5«s  KING'S  ECLECTIC  OBSTETRICS. 

method  by  which  the  first  indication  can  be  fulfilled  is  absolute  and 
positive  discontinuance  of  sexual  intercourse  for  a  year  or  longer — or 
for  such  a  length  of  time  as  may  be  required  to  effect  a  healthy  con- 
dition of  the  generative  functions.  I  am  aware  that  various  other 
means  may  be  suggested,  or  pursued,  to  prevent  pregnancy,  but,  in 
tin-  cases  under  consideration,  it  must  be  especially  borne  in  mind, 
that  not  only  is  an  avoidance  of  this  condition  required,  but  it  is  im- 
peratively demanded  that  the  sexual  organs  be  maintained  in  a  state 
of  quiet,  entirely  free  from  all  excitement,  and  which  can  only  be 
effected  by  rigid  abstinence. 

The  second  indication  is  to  be  accomplished  by  bestowing  a  care- 
ful attention  toward  both  the  uterine  and  general  systems,  employing 
tonics,  alteratives,  and  such  other  measures  as  may  from  time  to  time  be 
required.  The  tonics  which  I  have  found  more  commonly  beneficial  are, 
Macrotys,  Pulsatilla,  Achillea,  Aletris  farinosa,  Helonias  Dioica,  as  in- 
dicated; they  are  given  either  singly,  or  any  two  that  are  indicated 
may  be  combined  or  given  in  alternation.  Sulphate  of  Quinine  will 
sometimes  be  called  for.  The  Parturient  Balm  (Am.  Dispensatory), 
as  prepared  by  Lloyd  Bros.,  I  regard  as  an  excellent  uterine  tonic  also ; 
indeed,  the  vegetable  uterine  tonics,  generally,  may  be  employed  with 
advantage.  The  agents  which  I  term  uterine  tonics,  and  which  are 
described  in  the  Am.  Dispensatory,  appear  to  exert  an  especial  health- 
ful influence  upon  the  uterus,  but  of  their  peculiar  modus  opcrantli,  I 
am  free  to  confess  my  ignorance.  In  addition  to  the  special  tonics 
mentioned,  it  was  formerly  the  custom  of  the  earlier  Eclectics  to  ad- 
minister, in  these  cases,  alteratives,  so  called,  as  compound  syrups  of 
Sarsaparilla  and  Stillingia;  together  with  Iodide  and  Bromide  of  Po- 
tassium; at  present  these  are  seldom  thought  of.  The  general  tonics, 
however,  may  be  used  in  connection  with  the  special  treatment,  as  the 
practitioner  may  deem  proper. 

In  conjunction  with  this  treatment,  the  .bowels  must  be  kept  in  a 
soluble  condition  by  the  use  of  mild  laxatives,  so  given  as  to  produce 
one,  but  not  over  two,  alvine  evacuations  daily,  approximating  as 
nearly  as  possible  to  the  natural  healthy  discharges;  and  for  this  pur- 
pose I  prefer  the  trituration  of  Podophyllin,  or  the  small  Podophyl- 
lin  and  Hydrastin  pill;  this  may  be  omitted  occasionally,  and  cold  or 
tepid  enemata  employed,  as  may  be  found  to  suit  each  particular  case. 
In  many  cases,  a  few  doses  of  Cascara  Segrada,  or  Cascara  Cordial, 
will  prove  useful,  repeated  once  or  twice  a  day  for  several  consecutive 
days  at  a  time,  according  to  its  effect.  Active  purgation  is  invariably 


HEMORRHAGE    A.ND    ABORTION.  269 

to  be  prohibited,  except  in  plethoric  patients,  when  it  may  be  resorted 
to  every  week  or  two,  if  not  contra-indicated.  Bathing  the  surface 
daily  with  cold  or  tepid  water,  and  once  a  week  with  a  weak  alkaline 
solution,  and  drying  with  considerable  friction,  will  materially  assist 
in  the  restoration  to  health,  by  bringing  about  a  normal  condition  of" 
the  skin,  the  functions  of  which  will  be  found  more  or  less  impaired 
in  these  cases ;  the  shower-bath  has  also  been  advised,  either  of  rain- 
water or  salt  water,  and  where  it  is  applicable  it  will  usually  prove 
beneficial ;  its  temperature  should  range  between  75°  and  85°,  and  the 
best  time  for  using  it  is  upon  rising  in  the  morning.  Moderate  exercise 
will  be  found  indispensable,  and  an  avoidance  of  all  indolent  habits  im- 
perative, as  lying  in  bed  late  in  the  morning,  lying  down  after  a  meal- 
to  sleep,  sleeping,  on  feather  beds,  etc.  The  diet  should  be  light  but 
nutritions,  using  tender  fowls,  meats,  etc.,  but  always  avoiding  fats 
and  acids ;  and  very  weak  patients  may  use  Port  \vine,  porter,  or  other 
suitable  stimulants,  in  moderate  quantity,  during  the  dinner  meal. 
Occasionally,  a  change  of  air  will  prove  serviceable.  All  bathing 
must  be  omitted  during  menstruation.  By  a  perseverance  in  this 
course  for  one  or  even  two  years,  the  most  obstinate  cases  of  habitual 
abortion,  when  not  owing  to  uterine  adhesions,  may  be  cured;  and  it 
may  be  proper  to  remark,  that  should  pregnancy  occur  shortly  after 
dismissing  the  patient  as  cured,  it  is  very  necessary  that  close  atten- 
tion be  bestowed  upon  that  condition,  until  five  or  six  weeks  have 
passed  beyond  the  previous  aborting  period,  in  order  to  promote  the 
certainty  and  permanency  of  the  cure. 

It  may  be  briefly  stated  that  when  habitual  abortion  is  due  to  a 
morbid  nervous  excitability  of  the  reproductive  system,  to  premature 
disintegration  and  exfoliation  of  the  decidua,  Helonias,  Dioica  and 
Chlorate  of  Potassa  are  the  remedies;  when  due  to  uterine  displace- 
ments, overcome  the  trouble  by  using  supports,  if  necessary,  and  ad- 
minister Aletris,  Nux,  Parturient  Balm,  and  Belladonna;  when  to  a 
low  grade  of  uterine  inflammation,  Aconite,  Pulsatilla,  and  Macrotys; 
to  a  hard,  contracted  condition  of  the  cervix,  with  more  or  less  irrita- 
bility, Gelsemium,  Aconite,  Macrotys  and  Lobelia;  to  a  neuralgic  or 
rheumatic  aifection  of  the  uterus,  Aconite,  Macrotys  and  Gelsemium ;  if 
there  be  a  sluggishness  of  the  circulation,  lack  of  nervous  energy,  Nux, 
Xanthoxylon,  Gelsemium,  and  Rhus;  to  irritability  of  nerve  centers, 
Bromide  of  Potassium,  Belladonna,  Gelsemium,  Conium,  etc.  <  Any 
constitutional  disease  under  which  either  of  the  patients  may  be  labor- 
ing, will  require  the  proper  treatnient  for  such  affection. 


270  Kl.Ml's    K<   LIX'TIC    OI5STKTIJH-S. 

Before  leaving  this  subject,  I  wish  to  refer  to  two  things  which  may 
occa.-ion  .-nme  trouble  to  the  practitioner  in  the  treatment  for  prevent- 
ing abortion  ;  the  first  is,  the  difficulty  in  prevailing  on  some  females 
to  keep  quiet  and  confine  themselves  to  the  recumbent  position  for  a 
sufficient  length  of  time.  Xot  feeling  any  sickness,  nor  suffering  from 
any  pain,  the  patient  will  be  apt  to  treat  the  advice  of  her  physician, 
in  this  matter,  very  lightly,  unless  it  is  especially  urged  upon  her, 
explaining  to  her  the  consequences  of  a  different  course  of  action,  and 
the  advantages  attending  its  observance,  among  which  may  be  named 
the  diminution  of  the  tendency  to  abort,  by  checking  or  overcoming 
irritability  or  other  morbid  results  due  to  the  cause  of  such  tendency, 
and  the  strong  probability  of  its  permanent  cure,  when  the  habit  has 
been  overcome  in  any  one  pregnancy.  The  practitioner  can  not  be 
too  particular  in  regard  to  this  matter.  Though  he  must  not  forget 
that  too  long  a  continuance  in  the  recumbent  position  is  apt  to  give 
rise  to  morbid  symptoms  that  may  promote  instead  of  prevent  the 
abortion.  The  second  point  is  relative  to  the  decided  objections  which 
are  frequently  made  to  vaginal  examinations.  When  a  female,  during 
an  abortion,  objects  to  an  examination  of  this  kind,  and  the  symptoms 
are  not  very  urgent,  the  physician  will  treat  the  case  as  well  as  circum- 
stances will  permit;  but  when  the  hemorrhage  is  great,  and  the  serious 
consequences  that  may  happen  from  a  persistence  in  the  objection  have 
been  explained,  without  effecting  any  change  in  the  will  of  the  patient, 
it  would  be  improper  for  the  practitioner,  so- far  as  his  own  reputation 
alone  is  concerned,  to  assume  the  whole  responsibility  of  the  case. 
He  will,  therefore,  not  manifest  any  irritation,  nor  abruptly  leave  the 
patient,  but  will  state  to  the  friends,  or  the  patient,  that  the  case  has 
assumed  a  character  which  leads  him  to  desire  council,  and  then,  should 
any  fatal  result  ensue  from  a  continuance  of  such  obstinaucy,  this 
course  will  free  him  from  any  subsequent  imputations,  of  neglect, 
malpractice,  etc. 

In  a  premature  labor,  the  management  will  be  the  same  as  recom- 
mended for  labor  at  full  term ;  for  as  a  general  rule,  during  the  last 
three  months  of  pregnancy,  the  hand  may  be  introduced  within  the 
uterus  for  the  purpose  of  performing  any  manipulations  which  may 
be  required.  But  I  would  make  one  observation,  that  if  the  hand  of 
the  practitioner  be  very  large,  and  a  manual  operation  is  demanded 
during  the  seventh  or  eighth  month,  it  will  be  safer  for  the  patient, 
and  very  humane  on  the  part  of  the  medical  attendant,  to  send  for 
some  medical  friend,  with  a  small'  hand.  This  is  a  point  too  little 
heeded,  and  which,  of  itself,  is  frequently  a  cause  of  grave  results. 


LABOR.  271 


CHAPTER    XXIV. 

LABOR. 

LABOR,  or  PARTURITION,  is  that  function  by  which  the  matured 
fetus,  together  with  its  secundines,  are  expelled  from  the  uterus;  it 
occurs  at  the  end  of  nine  calendar  months  and  one  week,  or  about  two 
hundred  and  eighty  days  from  the  last  menstrual  appearance,  and  about 
one  hundred  and  forty  days  after  quickening.  A  few  days,  either 
previous  or  subsequent  to  this  time,  constitute  practically  no  material 
difference.  At  this  period,  the  hitherto  inactive  nervous  and  muscular 
systems  of  the  uterus  become  stimulated  into  action,  causing  contrac- 
tions of  this  organ,  which  are  always  accompanied  with  pain,  in  a 
greater  or  less  degree,  and  which  cease  only  when  the  uterus  has 
expelled  its  contents;  as  the  contractions  are  invariably  attended  with 
pains,  the  terms,  labor  pains,  and  uterine  contractions  are  employed 
synonymously.  As  a  general  rule,  labor,  though  painful  and  exposed 
to  danger,  may  be  expected  to  terminate  favorably,  and  without  arti- 
ficial aid.  The  average  duration  of  labor  is  six  hours,  or  according  to 
some  authors,  four,  but  which  depends  upon  the  amount  of  power  in 
action,  and  the  degree  of  resistance  which  is  presented.  Cases  have 
been  known,  in  which  labor  has  been  completed  in  ten  or  fifteen  min- 
utes, while  with  others,  again,  from  four  to  seven,  and  even  ten  days 
have  passed,  before  the  fetus  has  been  expelled  into  the  world.  The 
investigations  of  M.  Quetelet,  Dr.  Buck,  and  others,  indicate  that 
more  births  occur  at  night  than  during  the  day,  there  being  five  chil- 
dren born  at  night,  for  every  four  born  during  the  day ;  and  also,  that 
the  least  number  of  births  occur  at  midnight,  and  at  noon.  Yet 
these  day-births  may,  in  many  instances,  require  the  attention  of  the 
accoucheur  during  the  night. 

The  immediate  or  exciting  cause  of  labor,  is  not  satisfactorily  under- 
stood, though  physiologists  of  all  ages  have  advanced  various  theories. 
Thus,  some  have  attributed  it  to  a  supposed  struggling  of  the  fetus,  in 
an  endeavor  to  procure  a  more  adequate  amount  of  nourishment  than 
is  received  while  within  the  uterus ;  others  again,  have  supposed  it  to 
depend  upon  the  motions  of  the  fetus,  in  seeking  to  relieve  itself  from 
its  constrained  position,  to  remove  itself  to  a  less  elevated  tempera- 
ture ;  or,  to  obtain  access  to  the  atmosphere  for  the  purpose  of  breath- 


272  KING'S  ECLECTIC  OBSTETRICS. 

ing.  But  these,  or  any  other  theories  which  suppose  the  fetus  to  be 
the  principal  agent  in  its  own  expulsion,  are  now  known  to  be  incor- 
rect ;  the  fetus  is  merely  a  passive  agent  in  parturition,  and  a  dead  one 
is  expelled  as  easily  as  one  living.  Some,  viewing  the  uterus  alone  as 
possessing  the  power  necessary  to  effect  labor,  have  supposed,  that 
when  no  further  development  of  uterine  fiber  can  take  place,  the  con- 
tractions ensue;  others  assert,  that  they  commence  as  soon  as  the 
antagonizing  condition,  which  exists  between  the  fibers  of  the  cervix 
and  those  of  the  fundus,  are  overcome,  the  latter  having  the  prepond- 
erance of  action.  Dr.  Tyler  Smith  believes  the  expulsion  of  the  ovum 
to  be  effected  by  certain  changes  occurring  in  the  uterus,  and  which 
are  due  to  ovarian  excitement, — the  ovaries,  in  all  cases  of  pregnancy, 
assuming  a  regular  periodical  action  at  or  near  the  tenth  period  from 
the  last  menstruation.  This  hypothesis,  however,  is  inconsistent  with 
the  recent  views  concerning  nidation.  Cases  have  been  recently 
reported,  also,  in  which  the  ovaries  have  been  removed  during 
pregnancy  without  affecting  labor  in  the  least,  which  came  on  and 
was  perfectly  natural  at  the  proper  time.  Sir  James  Simpson  has 
advanced  the  opinion  that  parturition  is  the  result  of  a  separa- 
tion between  the  deciduous  membranes  and  the  uterine  walls,  and 
which  is  due  to  degeneration  of  the  decidual  structure  occurring 
toward  the  full  'term  of  pregnancy.  But  it  is  unnecessary  to  enter 
into  an  explanation  of  all  the  views  which  have  been  promulga- 
ted on  the  subject ;  suffice  it  to  say,  that  they  are  all  unsatisfactory,  and 
we  are  compelled  to  admit  that  it  is  the  result  of  an  unknown  natural 
law,  or,  as  expressed  by  Avicenna,  an  Arabian  physician  of  the  eleventh 
century,  "  that  at  the  proper  time,  labor  comes  on,  by  the  grace  of 
God ;"— or,  as  a  medical  man  once  remarked,  "  it  is  involved  in  as 
much  obscurity  as  the  cause  why  peaches  ripen  in  August,  and  straw- 
berries in  June."  But  though  the  researches  of  physiologists  have 
failed  to  discover  the  exciting  cause  of  labor,  they  have  established  the 
fact,  that  .as  with  all  other  uterine  functions,  periodicity  exists  in  this 
also ;  as  labor  manifests  itself  at  a  period  corresponding  to  that  of 
menstruation,  and  which,  but  for  the  conception,  would  have  been  a 
menstrual  term. 

The  principal  agents,  in  the  accomplishment  of  parturition,  are  the 
contractions  of  the  muscular  fibers  of  the  uterus,  aided  in  ordinary 
cases,  during  the  second  stage,  by -the  diapbragm  and  the  abdominal 
muscles ;  the  expulsory  efforts  of  all  these  agents  finally  determine  the 
evacuation  of  the  uterine  cavity,  which,  when  completed,  the  organ 
returns  to  its  non-gravid  state,  measuring  from  two  and  a  half  to  three 


LABOR.  273 

inches  in  length,  about  an  inch  and  a  half  in  width,  and  a  half  or 
three-fourths  of  an  inch  in  thickness.  The  pain,  which  attends  each 
uterine  contraction,  is  supposed  to  be  owing  to  the  pressure  these  con- 
tractions exert  upon  the  nerves  of  the  uterus,  and  also  to  the  constant 
traction  upon  the  circular  fibers  of  the  cervix,  by  the  longitudinal 
fibers. 

The  PREMONITORY  SIGNS  OF  LABOR  are  several;  a  sub- 
sidence, or  sinking  down  of  the  uterus  in  the  abdomen,  is  the  first,  and 
probably  most  striking ;  the  uterus,  which  had  previously  extended  to 
the  epigastric  region,  sinks  lower,  and  appears  to  spread  out  laterally. 
This  symptom  may  occur  as  early  as  two  weeks  previous  to  the  first 
pains  of  parturition,  but  usually,  it  is  observed  only  a  few  days  before. 
The  mechanical  impediment  to  respiration  being  thus  removed,  the 
female  experiences  much  relief,  she  respires  with  greater  ease,  feels 
lighter,  cheerful,  and  more  comfortable,  less  apprehensive,  and  is  better 
able  and  more  disposed  to  action  and  motion  than  she  had  been  for 
some  time  previously.  The  lowering  of  the  uterus  occasionally  pro- 
duces a  puffiness  and  swelling  of  the  lower  extremities,  rendering 
locomotion  difficult  or  impossible.  In  those  cases  where  nausea  or 
vomiting  was  present,  from  mechanical  pressure  upon  the  stomach, 
this  subsidence  at  once  relieves  the  patient  from  any  further  disposi- 
tion to  these  unpleasant  symptoms. 

This  falling  of  the  uterus  generally  takes  place  gradually,  so  that 
several  days  pass  before  the  patient  is  aware  of  it  •  sometimes  it  occurs 
suddenly,  or  in  a  short  time,  as  in  ten  or  twelve  hours.  As  the  head, 
covered  by  the  cervix,  must  enter  the  brim,  to  a  greater  or  less  extent, 
during  the  above  sinking,  this  is  looked  upon  as  a  symptom  indicative 
of  a  large*  or  well-formed  pelvis ;  being  seldom  observed  in  cases  of 
contracted  pelvis.  The  sinking  of  the  uterus  is  usually  considered  to 
be  the  result  of  the  complete  softening  of  the  cervix  uteri,  with  a 
relaxation  of  the  uterine  tissue,  which  permits  it  to  expand  laterally. 
The  late  Dr.  Meigs  considered  the  womb  wholly  passive  in  the  matter, 
it  being  pushed  downward  by  the  action  of  the  diaphragm  and 
abdominal  muscles.  In  some  females,  this  sinking  of  the  uterus*  is 
followed  by  an  unpleasant  sensation  of  weight  in  the  inferior  part  of 
the  pelvis,  with  an  irritable  condition  of  the  rectum  and  bladder, 
occasioning  frequent  and  ineffectual  desire  to  evacuate  these  organs, 
with  other  unpleasant  symptoms,  and  which  are  owing  to  pressure  of 
the  presenting  part  upon  the  bladder,  rectum,  blood-vessels,  etc.  These 
symptoms  can  not  be  relieved  by  treatment,  though  when  dysury  ia 
present  the  patient  may  urinate  freely,  by  placing  herself  upon  her 
18 


274  .  KING'S  ECLECTIC  OBSTETRICS. 

hands  and  knees,  with  the  hips  somewhat  elevated;  tenesmus,  when 
severe,  may  frequently  be  relieved  by  an  injection  of  starch,  or  elm 
infusion,  to  which  a  few  drops  of  Laudanum  have  been  added,  or  the 
support  oi  a  bandage  carefully  applied  might  prove  advantageous. 

One,  two,  or  three  weeks  previous  to  labor,  contractions  of  the 
uterus  are  frequently  observed,  to  which  the  names  of  painless  uterine 
contractions,  or  fibrillar  contractions,  have  been  applied.  The  patient 
experiences  a  squeezing  sensation  in  the  abdomen,  which  is  unaccom- 
panied with  pain,  and  which  occurs  at  intervals ;  during  its  presence, 
if  the  hand  be  placed  upon  the  abdomen,  the  uterus  will,  be  found  hard 
and  well-defined.  They  occur  much  sooner  in  primiparse  than  in  mul- 
tiparae,  and  are  supposed  to  be  sometimes  occasioned  by  the  child's 
motions ;  it  is  believed  that  these  painless  contractions  produce  gradual 
changes  in  the  cervix  and  os  uteri,  before  actual  labor  commences,  and 
may,  possibly,  assist  in  bringing  about  the  subsidence  of  the  uterus. 

In  connection  with  the  above  symptoms,  the  parts  become  somewhat 
relaxed  and  soft ;  though  it  is  very  doubtful  whether  any  relaxation 
of  the  pelvic  symphysis  occurs,  as  stated  by  some  authors.  With  these 
are  frequently  other  symptoms,  of  a  minor  character,  as  cramps  in  the 
lower  limbs,  swelling  of  the  labia,  increase  of  appetite,  etc.;  all  of 
which,  collectively,  indicate  the  approach  of  labor.  But  the  symptom 
upon  which  we  may  rely  as  an  evidence  that  labor  is  close  at  hand,  is 
a  muco-serolent  discharge,  called  by  nurses  and  midwives,  "  the  show" 
It  is,  usually,  observed  from  twelve  to  twenty-four  hours  previous  to 
the  commencement  of  actual  labor,  and  consists  of  a  greater  or  less 
quantity  of  mucus,  of  a  thin,  or  thick  and  viscid  character,  colorless, 
until  labor  has  commenced,  when  it  becomes  mixed  with  more  or  less 
blood.  The  mucus  is  an  exalted  secretion  of  the  follicles  of  the 
vagina,  and  is  not  to  be  regarded  as  an  indication  of  labor,  unless 
there  be  found  mixed  with  it  the  gelatinous  substance  which  had  pre- 
viously occupied  the  canal  of  the  cervix ;  and  the  blood  arises  from 
the  separation  of  the  membranes,  and  the  rupture  of  the  blood-vessels 
which  pass  from  the  cervix  uteri  to  the  fetal  membranes.  According 
to  Wigand,  when  the  mucus  is  thick  and  viscid,  it  is  mpre  favorable. 
It  evidently  prepares  the  passages  for  the  exit  of  the  fetus  by  lubrica-. 
ting  them.  It  may  be  proper  to  state  here,  that  the  show  4s  frequently 
absent,  and  also,  it  is  sometimes  observed  for  some  days  previous  to 
actual  labor ;  but  these  cases  may  be  looked  upon  as  the  exceptions  to 
the  general  rule;  for  it  is  usually  only  when  the  dilatation  of  the  os 
uteri  has  commenced,  with  descent  of  the  membranes,  that  the  san- 
guineous show  is  seen — it  is,  therefore,  a  good  sign  of  commencing 
labor. 


LABOR.  275 

Some  females  suffer  for  a  week  or  longer  previous  to  labor,  with  a 
restless  anxiety,  a  wakefulness  at  night,  pains  of  an  irregular  character 
about  the  uterus,  and  a  peculiar  nervous  irritability.  Others  again, 
especially  those  of  nervous  temperament,  are  attacked  with  rigors  or 
tremors,  of  greater  or  less  severity,  but  which  are  unattended  with 
any  feeling  of  cold.  These  rigors  are  usually  indicative  of  rapid  dila- 
tation of  the  os  uteri,  and  require  no  attention,  unless  accompanied 
with  a  sensation  of  cold.  They  frequently  occur  immediately  after 
labor,  and  are  sometimes  so  severe  as  to  create  some  alarm  in  the  minds 
of  the  friends  of  the  patient,  as  well  as  of  herself,  and  heating  drinks 
are  often  injudiciously  administered.  Some  warm  diluent  drink,  as  tea, 
and  an  extra  covering  over  the  patient  will  be  all  that  are  required. 
"  If  these  shiverings  be  followed  by  symptoms  of  fever,  this  must  be 
guarded  against;  if  by  severe  pains  in  the  head  and  abdomen, 
evidently  not  proceeding  from  the  labor,  then  you  may  suspect  that 
there  is  inflammation.  If  there  be  much  flushing  of  the  face,  throb- 
bings  of  the  carotids,* and  the  pulse  high,  there  is  reason  to  apprehend 
that  convulsions  may  supervene.  These  accidents  are  rare,  however ; 
and  when  the  rigors  occur  without  the  above  accompanying  symptoms, 
it  is  indicative  that  the  labor  will  be  active  and  its  termination 
speedy." — Blundell. 

Dilatation  -of  the  os  uteri  is  frequently  attended  with  nausea  or 
vomiting;  these  are  not  the  causes,  but  the  effects  of  the  dilatation, 
and  have  no  weight  in  sustaining  an  erroneous  impression  once  enter- 
tained, that  nauseants  or  emetics  favor  dilatation.  The  only  agents 
proper  to  overcome  a  rigid  os  uteri,  and  forward  the  dilating  process, 
are  relaxants.  The  practitioner  who,  in  the  first  stage  of  labor,  meets 
with  a  rigid  os  uteri,  which  seems  disposed  to  obstinately  maintain  its 
rigidity,  notwithstanding  the  strength  and  frequency  of  the  pains, 
will  observe  that  an  attack  of  spontaneous  vomiting  is  followed  by  a 
softening,  relaxation,  and  dilatation  of  the  os,  and  is  therefore  a 
favorable  symptom.  As  a  common  rule,  it  seldom  lasts  any  length 
of  time,  occasions  but  little  distress  to  the  patient,  and  needs  no  treat- 
ment. Occasionally  it  becomes  very  painful  and  obstinate,  requiring 
the  aid  of  the  physician;  a  few  drops  of  Laudanum,  or  of  tincture  of 
Gelsemium  in  a  draught  of  Soda  water,  will  usually  prove  sufficient 
to  check  it;  and  should  ^constipation  be  present,  a  laxative  enema 
must  be  administered.  It  is  rarely  that  a  sinapism  is  required  over 
the  epigastrium  ;  vomiting  during  a  protracted  labor  must  not  be 
confounded  with  that  just  referred  to;  it  is  a  very  unfavorable  sign, 
and  the  matter  ejected  will  be  in  large  quantity,  dark  colored,  and 
often  fetid ;  it  will  be  noticed  under  Rupture  of  the  Uterus. 


27(1  KI.\<;'s    ECLECTIC    OBSTETRICS. 

Usually  labor  commences  with  pain,  but  considerable  progress  may 
be  made  without  any  pain  ;  and  occasionally  the  patient  experiences 
no  pain  until  the  os  has  become  fully  dilated,  and  the  suffering  attends 
the  expulsive  effort  only.  True  labor  pains  are  intermittent  in  their 
character,  having  an  interval  of  ease  between  them;  at  first  they  are 
short  and  weak,  with  long  intervals,  but  gradually  become  stronger, 
more  frequent,  with  but  little  or  no  interval  between  them.  They  may 
be  suspended  by  many  causes,  as  passions  of  the  mind,  anger,  fear,  sur- 
prise, grief,  etc.;  sudden  and  unexpected  news,  or  even  the  entrance 
of  the  physician  into  the  parturient  room,  has  frequently  suspended 
the  labor  for  hours.  The  administration  of  stimulating  liquors,  which 
is  rather  common  with  some  old  nurses,  is  very  reprehensible ;  I  have 
known  labor  to  be  suspended  for  twelve  hours,  by  a  draught  of  gin- 
sling,  advised  for  the  purpose  of  easing  the  pains.  Anodynes,  as  Mor- 
phine or  Opium,  act  in  a  similar  manner;  a  full  dose  of  either  will 
overcome  uterine  contraction,  and  may  result  in  the  suspension  of 
labor  for  hours. 

There  are  two  kinds  of  pain  recognized  at  the  commencement  of 
labor,  which  arc  termed  true  and  false  pains,  and  it  is  of  importance 
to  the  patient,  as  well  as  to  the  reputation  of  the  physician,  to  be 
enabled  to  discriminate  between  them.  True  pains  are  regularly  inter- 
mittent, and  are  confined  to  the  uterine  region,  and  during  their  con- 
tinuance, if  the  hand  be  placed  on  the  abdomen,  over  the  uterus,  it 
will  be  found  to  contract  and  grow  harder  with  the  pain,  and  to 
become  softer  as  the  pain  passes  off;  upon  making  a  vaginal  examina- 
tion, the  os  uteri  will  be  found  to  contract  during  the  presence  of  a 
true  pain,  with  a  protrusion  of  the  membranes,  and  to  dilate  during 
its  absence. 

False  pains,  are  more  frequent  in  first  pregnancies  than  in  subse- 
quent ones;  they  are  irregular  or  constant,  and  exert  no  influence 
whatever  upon  the  uterus  or  os  uteri,  though  contraction  of  the  abdom- 
inal muscles  may  attend  them,  and  which  it  is  important  not  to  mistake 
for  uterine  contractions.  They  are  very  apt  to  harass  the  patient 
during  the  night,  and  disappear  through  the  day;  and  may  be  dependent 
upon  rheumatism  or  congestion  of  the  uterus,  intestinal  irritability, 
constipation,  overfatigue,  etc.,  and  are  sometimes  attended  with  febrile 
symptoms. 

True  pains,  commence  generally  in  the  back,  pass  around  to  the 
front  of  the  abdomen,  as  far  down  as  the  groin,  recur  at  regular 
intervals,  gradually  increase  in  frequency  and  power,  and  occasion 
contractions  of  the  uterus  and  os  uteri,  and  protrusion  of  the  bag  of 


LABOR.  277 

waters.  False  pains,  usually  commence  in  the  neighborhood  of  the 
fundus,  have  a  limited  extent,  are  irregular,  spasmodic,  often  quite 
sharp,  and  exert  no  influence  on  the  uterus  or  os.  There  appears  to 
be  a  disagreement  among  obstetricians  as  to  the  order  of  uterine  action, 
some  believing  it  to  commence  in  the  os  uteri  and  from  thence  to  pass 
to  the  fundus,  while  others  assert  that  it  begins  in  the  fundus,  passes 
in  an  undulate  manner  to  the  cervix,  and  then  returns  to  the  fundus, 
the  uterus  being  firmly  contracted  all  this  time.  As  to  the  manner 
in  which  peristaltic  uterine  action  occurs,  Leishman  cites  Wigand, 
who  has  taught,,  in  so  far  as  the  contractions  of  labor  are  concerned, 
as^follows:  The  earliest  contractions  always  take  place  at  the  neck, 
which  grows  tense.  From  this  point  the  vermicular  action  extends 
gradually  upward  in  the  direction  of  the  fundus,  from  whence  it 
again  returns  toward  the  os,  obvious  mechanical  advantages  being 
attendant  upon  this  method  of  action ;  my  own  observations  lead  me 
to  coincide  with  the  latter  opinion. 

To  remove  false  pains,  we  must  endeavor  to  learn  their  cause;  if 
they  be  owing  to  intestinal  irritabilitv,  or  constipation,  a  mild  pur- 
gative, or  a  purgative  enema  will  answer;  if  from  overfatigue,  rest 
must  be  enjoined,  and  an  opiate  may  be  administered,  or,  what  is 
better,  Sp.  Tr.  Pulsatilla  or  Valerian ;  if  from  rheumatism,  the  com- 
pound powder  of  Ipecacuanha  and  Opium,  with  an  occasional  lax- 
ative, will  remove  them,  or  specific  tinctures  of  Gelsemium,  Macrotys 
and  Aconite.  -Ordinarily  a  few  doses  of  compound  powder  of  Ipecac- 
uanha and  Opium  (Dover's  Powder)  will  give  relief.  If  the  patient 
is  annoyed  by  a  return  or  a  continuance  of  the  pains,  I  would  recom- 
mend half  teaspoonful  doses  of  the  Parturient  Balm  three  times  daily. 
This  preparation  has  a  direct  and  kindly  action  on  the  uterus,  and 
satisfactory  results  will  follow  its  administration. 

I  have  met  with  many  cases,  in  practice,  where  the  pains  were  sharp, 
regular,  occurring  at  short  intervals,  with  dilatation  of  the  os  to  nearly 
the  size  of  a  silver  half  dollar,  and  everything  indicating  a  speedy 
labor ;  when,  after  waiting  a  few  hours,  the  pains  ceased,  and  did  not 
recur  again  for  several  days ;  the  longest  time  I  have  observed  to  pass 
in  such  cases,  before  the  re-appearance  of  labor,  was  two  weeks ;  I  do 
not  pretend  to  account  for  these  anomalies. 

Labor  has  been  variously  classified  by  different  authors,  for  the 
purpose  of  facilitating  an  acquaintance  with  it.  The  arrangement 
which  I  have  adopted,  is  one  followed  by  several  recent  writers,  and 


278  KINO'S  ECLECTIC  OBSTETRICS. 

will  be  found  fully  sufficient  for  all  practical  purposes;  it  divides  labor 
into  four  classes,  viz.: 

1.  Natural  labor,  in   which   the  fetal   head   presents,    and   where 
delivery  is  effected  within  twenty-four  hours,  without  the  aid  of  any 
artificial  power. 

2.  Difficult  labor,  also  called    lingering,  tedious,  and  protracted,  in 
which   the   fetal  head   presents,  but  where    labor   continues  beyond 
twenty-four  hours,  and  may  require  some  medicinal,  manual,  or  instru- 
mental assistance. 

3.  Preternatural  labor,  in  which  some  other   part   than   the    head 
presents,  where  there  is  a  prolapse  of  the  umbilical  cord,  or  a  plurality 
of  children. 

4.  Complicated   labor,  in  which   some  serious  accident  occurs,  not 
connected  with  the  presentation  of  the  fetus. 

From  its  commencement  to  its  termination,  natural  labor  is  one  con- 
tinued process,  marked,  however,  by  certain  peculiarities  which  have 
led  to  a  division  of  it,  among  obstetricians,  into  several  parts  or  stages. 
The  most  usual,  and,  probably,  the  most  natural  division,  is  that  of 
Denman,  who  describes  labor  as  consisting  of  three  stages.  The  first 
stage,  extending  from  the  commencement  of  labor  to  the  full  dilata- 
tion of  the  os  uteri ;  the  second  stage,  occupying  the  period  between 
the  dilatation  of  the  os,  until,  and  including,  the  birth  of  the  child ; 
and  the  third  stage,  including  the  delivery  of  the  placenta.  The  time 
which  each  of  these  stages  occupies  varies  with  different  patients 
according  to  circumstances. 

In  the  FIRST  STAGE  OF  LABOR,  the  stage  of  dilatation,  the  os 
uteri  will,  at  an  early  period,  be  found  looking  toward  the  sacrum,  and 
will  gradually  approach  toward  the  center  of  the  brim  as  labor  advances. 
The  pains  which  are  present  during  this  stage,  are  of  a  peculiar  character, 
and  are  variously  described  by  patients,  as  "  grinding,  cutting,  or  saw- 
ing." They  are  entirely  confined  to  the  uterus,  producing  no  sensible 
change  in  the  position  of  the  fetus,  but  influence  the  condition  of  the  os 
uteri,  dilating  it  that  the  head  of  the  fetus  may  pass  through.  These 
are  termed  the  preparatory  pains,  and  the  rapidity  with  which  dilata- 
tion ensues,  very  much  depends  on  their  force  and  frequency. 
Generally,  it  proceeds  more  rapidly  during  the  latter  half  of  the  first 
stage,  and  is  effected  more  slowly  in  primiparse  than  in  multiparse. 

These  pains  commonly  commence  in  the  back,  extend  to  the  loins, 
from  thence  to  the  front  of  the  abdomen  and  pubes,  a'nd  terminate  in 


LABOR.  279 

the  neighborhood  of  the  groins,  or  upper  part  of  the  thighs.  Some- 
times females  are  able,  especially  in  the  first  part  of  this  stage  of  labor, 
to  conceal  these  pains,  but  usual]}'  they  cause  much  suffering,  obliging 
the  patient  to  suspend  for  the  time  whatever  occupation  she  may  be 
engaged  in,  and  forcing  from  her  moans,  or  a  short  and  fretful  cry. 
The  pains  are  not  attended  with  any  bearing-down  or  expulsive  efforts, 
and  the  practitioner  should  be  careful  to  caution  the  patient  against 
any  of  those  voluntary  bearing-down  efforts  during  the  preparatory 
stage  of  labor,  w^ich  are  so  often  unwisely  advised  by  ignorant  nurses 
and  midwives.  As  the  pains  proceed,  they  increase  in  severity,  and 
last  for  a  longer  time,  having  shorter  intervals  between  them,  and 
when  absent,  the  female  manifests  a  certain  degree  of  restlessness  and 
uneasiness ;  the  pain  in  the  back  may  sometimes  be  relieved  by 
pressure,  but  not  always,  and  when  this  is  the  case,  the  matter  should 
be  left  to  the  care  of  the  friends,  and  not  to  the  practitioner,  who  must 
be  careful  not  to  fatigue  himself  at  an  early  period,  lest  he  be  unable 
to  afford  more  important  aid  at  an  advanced  stage,  should  it  be 
required.  Sometimes  each  pain  is  preceded  by  a  slight  nervous  tremor 
or  shivering,  and  it  is  not  uncommon  for  nausea  and  vomiting  to 
attend  the  whole  of  the  first  stage.  The  vomiting  in  beneficial,  in  con- 
sequence of  its  removing  crude  and  indigestible  substances  from  the 
stomach,  when  they  are  present,  and  also  from  the  relaxation  of  the  os 
uteri,  which  is  certain  to  accompany  it.  When  it  is  very  severe  and  an- 
noying, I  have  frequently  checked  it  by  administering  a  hot  drink  ;  the 
common  tea  or  hot  water  may  be  used.  Frequently  the  female  becomes 
irritable,  restless,  impatient  or  despondent,  and  may  suy  or  do  things 
which  are  extremely  unpleasant  to  the  physician,  but  which  good  sense 
will  teach  him  to  pass  by  in  a  pleasant,  friendly  manner,  at  the  same 
time  endeavoring  to  console  and  encourage  his  patient.  By  an  atten- 
tion to  the  moans  or  peculiar  cries  of  the  female,  her  expressions,  and 
respirations,  the  practitioner  can  frequently  determine  the  first  from 
the  second  stage  of  labor.  Respiration  will  be  free,  or  if  the  breath 
be  suspended,  it  will  be  for  a  few  seconds  only,  without  any  straining 
or  bearing-down  efforts,  and  which  is  the  reverse  of  the  second  stage. 
Generally,  there  is  no  increase  of  the  temperature  of  the  surface, 
and  no  perspiration,  especially  during  the  first  half  of  this  preparatory 
stage;  and  the  pulse  is  seldom  quickened  until  the  second  stage. 
Hohl  has  remarked,  however,  that  during  the  first  part  of  a  pain,  the 
pulse  will  be  found  more  frequent,  then  remain  stationary  for  a 
moment,  and  afterward  subside  into  its  natural  action.  Upon  auscul- 
tation, just  as  a  pain  is  coming  on,  there  will  l)e  heard,  a  short,  rushing 


280  KIXc's    KCLKCTIC    OUSTKTKK  S. 

sound,  apparently  proceeding  from  the  liquor  amnii,  and  which  ma}7, 
probably,  be  caused  in  a  degree  by  the  fetal  movements,  or  the  mus- 
cular contractions  of  the  uterus,  at  the  same  time  all  the  tones  of  the 
uterine  pulsations  become  stronger  and  more  distinct;  sounds  also,  are 
heard  which  were  not  noticed  before,  especially  those  of  a  piping, 
resonant  character,  and  which  seem  to  vibrate  through  the  stethoscope. 
As  the  pain  reaches  its  maximum,  these  sounds  become  gradually 
dull  or  altogether  inaudible,  and  return  with  the  decline  of  the 
pain,  resuming  the  original  character  during  the  intervals  between 
the  pains. 

If  we  examine  through  the  abdominal  walls,  during  the  pains,  the 
body  of  the  uterus  will  be  found  hard  and  rigid,  and  thrown  forward, 
so  as  to  place  its  long  diameter  in  correspondence  with  the  axis  of  the 
superior  strait,  and  without  which  the  labor  would  progress  writh  much 
difficulty ;  as  the  pain  ceases,  the  organ  relaxes.  An  examination  per 
vaginam  will  detect  the  os  uteri  high  up,  looking  toward  the  promon- 
tory of  the  sacrum,  and  more  or  less  dilated;  most  commonly,  it  will 
admit  the  end  of  the  index  finger,  at  the  commencement  of  labor. 
If  it  be  much  dilated,  each  pain  will  cause  a  protrusion  of  the  mem- 
branes into  the  vagina,  which  is  called  the  "bag  of  waters" — and  the 
presenting  part,  if  it  be  low  down,  will  be  found  to  ascend  during  each 
contraction,  but  will  resume  its  original  position  as  the  pain  subsides. 

This  ascent  of  the  head  is  due  to  the  liquor  amnii,  which,  being 
compressed  downward  by  the  uterine  contraction,  must  exert  an  action 
that  will  cause  any  body  floating  in  it  to  ascend,  in  accordance  with 
the  laws  of  hydrostatics. 

The  bag  of  waters  is  the  name  given  to  that  portion  of  the  mem- 
branes which  protrudes  through  the  os  into  the  vagina  during  a  pain. 
Its  shape  is  generally  round  or  elliptical,  and  sometimes  elongated, 
like  a  sausage,  and  which  is  supposed  to  be  owing  to  the  nature  of 
the  presentation.  During  a  pain  it  is  hard,  and  must  be  carefully 
touched,  as  it  frequently  becomes  ruptured  from  the  slightest  cause; 
as  the  pain  disappears,  it  becomes  lax  and  wrinkled,  and  recedes  into 
the  uterine  cavity.  It  undoubtedly  assists  in  the  dilatation  of  the 
os  uteri.  It  usually  ruptures  at  its  dependent  extremity,  and  when 
the  rupture  occurs,  that  portion  of  the  liquor  amnii,  situated  between 
the  fetal  head  and  the  membranes,  escapes,  the  head  descends  and 
prevents  the  too  rapid  flow  of  the  remainder,  and  delivery  is  soon 
effected.  Sometimes  the  rupture  occurs  high  up,  the  waters  escape 
gradually,  and  the  head  being  in  immediate  contact  with  the  mem- 
branes, the  child  may  be  born  with  a  caul,  especially  when  the 


LABOR.  281 

membranes  in  contact  with  its  head  remain  unbroken.  Rupture 
of  the  membranes  may  occur  at  any  period  of  the  first  stage  of  labor, 
depending  on  their  power  of  resistance ;  if  it  should  happen  at  an 
early  period,  it  will  delay  the  delivery,  and  may  cause  a  difficult  labor. 
Sometimes  it  is  not  ruptured  at  all,  but  the  fetus  is  born  enveloped  in 
the  membranes,  yet  such  cases  are  rare.  It  is  important  for  the  practi- 
tioner, as  a  general  rule,  to  retain  the  membranes  entire,  if  possible, 
until  complete  dilatation  of  the  os  uteri  has  been  effected. 

The  os  uteri  may  present  several  variations  in  its  character  during 
the  first  stage  of  labor.  Thus,  it  may  be  found  thick,  soft,  spongy, 
moist,  dilated,  or  if  not  dilated,  relaxed,  and  dilatable,  which  is  a 
favorable  condition;  or  it  may  be  thick,  hard,  rigid — perhaps  likewise, 
hot,  dry,  and  tender,  feeling  somewhat  like  cartilage,  and  which  is  an 
unfavorable  condition,  generally  indicating  a  difficult  labor.  Toward 
the  latter  part  of  the  first  stage  of  labor  it  may  be  found  soft,  moist, 
cool,  sensitive  to  the  touch,  but  not  painful,  and  so  thin  that  the 
presenting  part  of  the  fetus  can  be  distinctly  felt  through  its  substance ; 
this  is  likewise  a  favorable  condition.  Or,  it  may  be  thin,  hard,  rigid, 
perhaps  tender  when  touched,  with  its  edge  tightly  embracing  the 
presenting  part  of  the  fetus,  like  a  piece  of  cord;  this  is  an  unfavor- 
able condition,  indicating,  as  with  the  former  instance  of  rigidity,  a 
difficult  labor.  Rigidity  of  the  os  uteri  will  be  treated  of  hereafter. 

To  return  to  the  progress  of  the  preparatory  stage  of  labor;  the 
os  uteri  becomes  thinner  and  softer  as  the  labor  advances,  its  dilatation 
continues  to  increase,  and  usually,  the  head  of  the  fetus  passes  the 
superior  strait,  occupying  a  considerable  portion  of  the  pelvic  cavity, 
until  complete  dilatation  having  been  effected,  the  os  uteri  is  wholly 
effaced,  and  the  head  passes  through  into  the  vagina.  Sometimes, 
however,  the  anterior  lip  may  be  felt,  thick  and  somewhat  cedematous, 
between  the  fetal  head  and  the  pubis,  requiring  no  interference,  unless 
the  progress  of  labor  be  impeded  by  inefficient  pains,  but  which  is 
more  commonly  encountered  during  the  second  stage.  Generally, 
if  the  membranes  have  not  previously  given  way,  they  rupture  at  this 
moment,  and  the  liquor  amnii  escapes  with  a  gush.  Sometimes  they 
do  not  rupture  but  pass  through  the  vagina  and  its  orifice,  upon  the 
external*  parts,  which  they  aid  in  dilating.  With  the  full  dilatation 
of  the  os  uteri,  which  may  be  accomplished  in  from  four  to  eight 
hours,  the  first  stage  of  labor  terminates.  The  duration  of  this  stage, 
however,  varies  with  different  women,  and  frequently  with  the  same 
women  in  different  labors,  and  almost  always  occupies  more  time  with 
primiparse. 


282  KING'S  ECLECTIC  OBSTETRICS. 

Tlie  os  uteri  liaving  become  fully  dilated,  the  SECOND  STAGE 
OF  LABOR  the  propulsive  and  expulsive  stage  now  commences, 
between  which  and  the  first  stage,  especially  if  the  membranes  have 
ruptured,  there  is  usually  a  short  interval  of  freedom  from  pain;  and 
with  some  women,  several  hours  of  rest  will  follow  without  any  pain. 

A  new  order  of  things  is  now  presented,  the  pains  become  much 
stronger  and  more  perfect,  and  change  from  the  grinding  character 
to  that  of  the  expulsive,  and  it  is  only  in  this  stage  that  the  accessory 
powers  of  the  diaphragm  and  abdominal  muscles  are  called  into 
action — the  rectus  abdominis,  the  external  and  internal  oblique,  and 
the  transversalis.  The  action  of  these  muscles  is  rarely  witnessed 
until  the  os  uteri  has  retracted  over  the  head,  and  then  it  commences 
powerful  and  continued.  The  patient  fills  her  chest  with  air,  and 
fixes  it  as  a  fulcrum  for  muscular  exertion  by  closing  the  glottis, 
which  prevents  the  escape  of  the  air;  she  then  grasps  any  object  near 
her  for  support,  fixing  the  feet  firmly  upon  some  immovable  point, 
and  forcibly  bears  down.  Any  noise  or  outcry  is  usually  suspended 
until  the  termination  of  the  pain,  the  breath  being  held  until  it  is 
over;  though,  sometimes  when  the  pain  continues  for  a  long  time, 
a  kind  of  half-breath  with  a  short  cry  will  be  uttered  once  or  twice 
during  the  pain,  apparently- for  the  purpose  of  more  firmly  renewing 
the  condition  necessary  for  powerful  bearing-down  efforts.  The  tone 
is  not  of  the  fretful,  moaning  character  of  the  first  stage,  but  is  of  a 
straining  character,  sometimes  terminating  in  a  short  cry  and  gasping 
for  breath,  and  affords  a  good  test  for  the  practitioner  to  determine 
the  second  stage  from  the  first.  Between  each  pain  there  is  a  perfect 
condition  of  repose,  and  should  this  stage  be  much  prolonged,  the 
patient  will  frequently  doze  during  the  intervals.  The  dozing  is 
owing  to  fatigue,  and  partly  to  the  congestion  about  the  face  and  head, 
the  result  of  the  suppressed  breathing,  and  requires  no  interference, 
unless  it  be  excessive  and  attended  with  severe  pain  in  the  head, 
which  are  the  premontory  signs  of  convulsions. 

During  the  presence  of  a  pain,  and  while  the  patient  is  so  power- 
fully exerting  herself,  the  heat  of  the  skin  becomes  increased,  also  the 
frequency  of  the  pulse,  the  eyes  are  bright,  profuse  perspiration  takes 
place,  and  during  the  suspension  of  respiration,  the  vessels  of  the  head 
and  neck  become  congested  from  an  arrest  of  the  circulation,  the  face 
being  florid  and  sometimes  purple.  The  patient  manifests  much  agita- 
tion, though  she  bears  her  sufferings  with  more  patience  and  cheerful- 
ness than  in  the  first  stage,  and  appears  to  have  changed  her  fretful  or 
despondent  condition  to  one  of  courageous  determination.  Vomiting. 


LABOR.  283 

occasionally  occurs  in  this  stage  also,  and  is  usually  a  favorable  symp- 
tom, unless  it  be  dark,  greenish,  and  fetid,  with  fever,  suspension  of 
pains,  and  tenderness  of  abdomen,  when  it  is  a  very  unfavorable  indica- 
tion. 

Upon  making  a  vaginal  examination,  the  head  of  the  child  will  be 
found  in  the  pelvic  cavity,  each  pain  forcing  it  toward  or  upon  the 
perineum;  the  pressure  exerted  upon  the  head  causes  a  wrinkling  of 
the  integuments,  and  overlapping  of  the  parietal  bones;  and  if  the 
external  parts  are  unyielding,  the  labor  being  protracted,  a  tumor, 
caput  succedaneum,  will  form  under  the  scalp,  owing  to  an  effusion  of 
blood  into  the  loose  cellular  membrane  between  the  bones  and  integu- 
ments. The  head  most  usually  lies  in  an  oblique  or  diagonal  position 
in  the  pelvis,  having  the  occiput  looking  toward  the  left  acetabulum, 
and  the  forehead  to  the  right  sacro  iliac  symphysis,  the  most  dependent 
part  being  the  vertex.  As  the  head  is  forced  onward  by  the  painsr 
the  soft  parts  of  the  canal  through  which  it  is  passing  become  gradu- 
ally dilated,  rotation  of  the  head  ensues,  the  perineum  becomes  thin 
and  distended,  and  the  occiput  appears  between  the  labia.  On  the 
subsidence  of  the  pain  the  head  recedes,  and  the  external  parts  resume 
their  natural  appearance ;  but  on  the  return  of  another  pain,  the  head 
is  thrust  still  further  down,  the  distension  of  the  perineum  is  increased, 
the  anus  projects,  and  probably  there  may  be,  at  this  time,  a  discharge 
of  the  contents  of  the  rectum,  as  well  as  of  the  bladder.  The  patient 
suffers  most  intensely,  as  manifested  by  her  loud,  piercing  cries,  or  by 
deep,  suppressed  groans.  As  the  pains  continue,  the  distension  of  the 
perineum  increases,  it  becomes  thinner,  tense,  elongated,  and  widened, 
the  vulva  begins  to  unfold,  and  the  head  advances  to  the  external 
labia ;  with  the  subsidence  of  the  pains  the  elasticity  of  the  perineum 
forces  the  head  to  recede  upward,  to  be  again  thrust  forward  upon 
their  renewal.  Finally,  all  resistance  is  overcome,  a  succession  of 
strong,  expelling  pains,  called  double  pains,  because  they  follow  each 
other  so  rapidly,  that  a  new  one  commences  before  the  previous  'one 
has  terminated,  causes  the  head  to  emerge  from  the  vulva,  while,  at  the 
same  time,  the  female  utters  a  sharp,  agonizing  shriek,  which  is  fol- 
lowed by  panting  and  sobbing,  and,  after  a  short  period  of  repose,  the 
remainder  of  the  child  is  delivered.  As  soon  as  the  head  is  born  the 
child  commences  respiring  and  crying,  or  if  this  does  not  immediately 
occur,  it  will  as  soon  as  the  mucus  in  the  mouth  is  removed  by  means 
of  a  finger. 

Dilatation  of  the  perineum,  like  that  of  the  os  uteri,  is  accomplished 
in  different  cases,  at  various' periods  of  time,  sometimes  requiring  sev- 
eral hours  before  it  is  completed,  especially  in  first  labors,  and  as  often 


2X4  KIND'S    ECLECTIC    OBSTETRICS. 

requiring  only  a  few  pains.  Its  distension  is  so  great  during  the 
passage  of  the  head  and  shoulders  as  to  endanger  its  laceration,  which 
must  be  carefully  guarded  against  by  the  practitioner. 

After  delivery  of  the  child,  the  female  is  relieved  from  all  her  suf- 
fering and  anxiety,  and  enjoys  a  greater  or  less  period  of  repose,  until 
the  THIRD  STAGE  OF  LABOR  or,  supplemental  stage,  commences; 
though,  usually,  she  will  be  much  excited  or  exhausted,  with  a  rapid 
pulse,  flushed  countenance,  and  profuse  perspiration.  The  pains  are 
again  renewed,  but  with  less  severity  than  before,  and  after  one  or  two 
have  been  experienced,  the  placenta  and  membranes  are  expelled. 
Sometimes  the  placenta  is  delivered  with  the  same  pain  that  expelled 
the  child,  but  usually  from  a  few  minutes  to  half  an  hour  or  longer, 
elapses  before  this  takes  place ;  as  the  placenta  is  not,  commonly,  com- 
pletely detached  before  the  birth  of  the  child. 

The  delivery  of  the  placenta  is  usually  followed  by  a  variable 
amount  of  blood,  not  to  exceed  a  pint  in  normal  cases ;  and  frequently 
a  shivering,  with  chattering  of  the  teeth  ensues,  which,  however,  is 
not  the  result  of  cold.  When  the  placenta  is  not  delivered  within 
an  hour  after  the  birth  of  a  child,  it  must  be  managed  as  a  retained 
placenta.  If  the  distance  between  the  perforation  in  the  membrane, 
through  which  the  fetal  head  passed,  and  the  placenta,  be  ascertained 
after  their  expulsion,  it  will  give  us  the  exact  distance  between  the 
placenta  and  os  uteri,  and  thus  enable  us  to  estimate  the  situation  of 
the  placenta  in  utero. 

After  the  secundines  have  been  expelled,  the  uterus  contracts,  and 
gradually  returns  to  its  normal,  unimpregnated  condition,  and  it  may 
be  felt  through  the  abdominal  walls,  directly  above  the  pubic  sym- 
physis,  soon  after  the  delivery,  imparting  the  sensation  of  a  hard, 
round  tumor,  somewhat  like  a  large  ball.  For  a  few  days  subsequently, 
the  exposed  vessels  of  the  uterus,  at  the  placental  site,  discharge  a 
sanguineous  fluid  called  the  lochia,  which  changes  to  a  greenish,  or  a 
creamy  hue,  having  a  peculiar  odor,  and  which  gradually  disappears  as 
the  uterus  resumes  its.  non-gravid  state. 

Professor  Haughton,  who  has  bestowed  considerable  attention  upon 
the  subject,  concludes,  from  his  investigations,  that  the  involuntary  or 
uterine  effort  during  labor  amounts  to  3.4  pounds  to  the  square  inch, 
while  the  voluntary  or  abdominal  force  equals  38.6  pounds  to  the 
square  inch,  giving  a  total  of  42  pounds.  Now,  if  it  be  admitted  that 
the  diameter  of  the  fetal  head  is  4£  inches,  we  have  a  propelling 
power,  exerted  upon  its  surface,  during  uterine  action,  equivalent  to 
593  pounds.  And  as  the  voluntary  force  exceeds  the  involuntary  more 


MANAGEMENT  OF  NATURAL  LABOR.  285 

than  ten  times,  it  may  readily  be  seen  how  the  progress  of  labor  must 
be  impeded  by  destroying  the  will  power  under  the  influence  of  anaes- 
thetics. It  will,  however,  become  necessary  in  some  cases  of  nervous 
patients,  to  allay  the  suffering,  to  a  degree,  by  allowing  a  few  inspira- 
tions of  chloroform  during  the  pain,  withdrawing  it  during  tho  inter- 
val between  the  pains,  and  so  continue  during  the  last  throes  of  the 
second  stage.  It  is  very  probable,  however,  that  the  real  force  ex- 
erted is  less  than  .that  named  above,  •though  we  are  aware  it  is  very 
great  from  the  difficulty  experienced,  if  not  impossibility,  of  intro- 
ducing the  hand  into  the  uterine  cavity  during  a  pain,  from  the  in- 
fluence of  these  pains  upon  the  accoucheur's  hand  when  within  this 
cavity,  as  well  as  from  the  force  required  in  delivering  the  head  with 
forceps,  in  the  absence  of  pains,  and  when  the  head  is  in  the  upper 
part  of  the  vagina. 


CHAPTER    XXV. 

MANAGEMENT  OF  NATURAL  LABOR. 

IT  must  be  remembered  by  the  practitioner,  that  labor  is  not  a 
case  of  sickness,  but  a  function  natural  to  females,  for  which  as  com- 
plete provision  is  made  as  for  any  other  function  of  the  system; 
and  all  that  he  can  do  is,  to  carefully  witness  and  superintend  its 
progress,  without  any  improper,  or  uncalled  for  interference.  Indeed, 
the  ma"xim  of  every  obstetrician  should  be,  "allow  nature  to  pursue 
her  own  course,  without  any  officious  intermeddling."  But,  sometimes, 
as  is  the  case  with  other  functions,  this  of  labor  may  fail  from  certain 
causes,  and  it  is  only  in  these  failures,  when  the  natural  powers  are 
insufficient  to  safely  finish  the  labor,  that  the  aid  of  the  practitioner  is 
demanded ;  and  it  is  his  duty  to  thoroughly  inform  himself  relative  to 
all  the  circumstances  which  may  require  his  assistance,  as  well  as  the 
means  of  removing,  or  overcoming  them,  in  the  safest,  gentlest,  and 
most  successful  manner.  In  a  natural  labor,  nothing  further  is 
required,  after  having  satisfied  one's  self  that  the  presentation  and 
condition  of  the  parts  are  normal,  than  to  patiently  await  the  ex- 
pulsion of  the  head,  receive  it  and  the  rest  of  the  child,  tie  and 
separate  the  cord,  and  remove  the  placenta.  But  as  the  young 
physician,  especially,  may  be  at  a  loss  how  to  proceed  in  the  manage- 
ment of  a  case  of  this  kind,  I  shall  lay  down  a  line  of  conduct,  an 
attention  to  which,  I  trust,  will  be  found  advantageous;  for  without 


KIN<;'s     KCLKCTIC    »  MISTKTI:  K  'S. 

a  knowledge  of  the  proper  course  to  be  pursued,  a  very  slight  inter- 
ference of  an  improper  character,  may  convert  a  simple  .case  of  labor 
into  a  protracted  or  even  dangerous  one. 

Having  been  engaged  to  attend  a  female  in  her  confinement,  the 
physician  should  endeavor  so  to  arrange  his  business,  that,  at  the 
expected  time,  he  can  readily  be  found  by  those  who  are  dispatched 
to  summon  his  presence  to  the  parturient  chamber.  He  should  obey 
the  summons  as  promptly  as  possible,  not  only  that  he  may  secure 
the  confidence  of  the  patient  and  her  friends,  by  displaying  a  readi- 
ness, cheerfulness,  and  willingness  to  accord  his  services,  but  more 
especially  that  he  may  be  in  time  to  rectify  any  accidents  which  may 
occur,  and  to  which  all  females  are  liable  during  parturition — as, 
presentation  of  the  superior  extremities,  uterine  hemorrhage,  and  (in 
cases  where  delivery  takes  place  rapidly,  with  but  a  few  pains),  an 
encircling  of  the  neck  of  the  child  by  the  umbilical  cord.  If  he 
reside  in  a  city,  it  is  hardly  necessary  to  take  along  with  him  any 
medicines  or  instruments,  lest  he  be  tempted  to  needlessly  administer 
the  one,  or  rashly  employ  the  other;  beside,  when  either  are  required, 
they  can  readily  be  obtained,  and  in  sufficient  season.  Perhaps  a 
flexible  male  catheter,  and  some  compound  powder  of  Ipecacuanha 
and  Opium,  may  be  the  only  exceptions  to  this  rule.  But  with  a 
practitioner  in  the  country,  who  frequently  has  to  attend  patients  many 
miles  distant  from  his  office,  and  where  the  delay  occasioned  by 
sending  for  the  requisite  articles  may  prove  fatal  to  his  patient,  the 
case  is  entirely  different.  He  should  take  with  him,  his  instruments, 
and  several  vials,  containing  compound  powder  of  Ipecacuanha  and 
Opium,  Ergot,  Macrotys,  some  preparation  for  uterine  hemorrhage, 
as  tincture  of  Cinnamon,  and  tincture  of  Gelsemium,  or  compound 
tincture  of  Lobelia  and  Capsicum.  He  should  likewise  include  an 
.anaesthetic,  as  Chloroform,  Ether,  or  a  mixture  of  the  two.  The  use 
of  any  of  these  may  not  generally  be  needed ;  but  if  one  patient 
among  fifty  is  saved,  or  benefited,  the  physician  will  be  fully  repaid 
for  his  attention  to  these  patients. 

On  reaching  the  patient's  house,  he  should  have  his  arrival  made 
known  to  her  before  he  enters  the  room,  as  it  is  frequently  the  ease, 
especially  in  first  labors,  that  the  sudden  introduction  of  the  physician 
has  caused  a  suspension  of  the  pains  for  some  time ;  beside,  the  female 
may  wish  to  have  her  room  arranged  before  the  entrance  of  the  phy- 
sician, or  she  may  be  very  averse  to  his  presence,  requiring  some  time 
for  her  friends  to  remove  her  scruples.  But  this  can  not  always  be 
done,  for  with  the  poorer  classes,  who  occupy  but  one  room,  he  is 


MANAGEMENT  OF  NATURAL  LABOR.  '^87 

obliged  to  be  ushered  into  the  patient's  presence  at  once,  and  his  good 
sense  will  teach  him  how  to  conduct  himself  in  such  cases.  Unless 
from  the  general  symptoms  and  appearance  of  the  patient,  he  suspects 
the  second  stage  of  labor  to  be  at  hand,  or  where  symptoms  are  present 
which  demand  his  immediate  attention,  it  will  be  proper  to  remove 
any  embarrassment  under  which  she  may  be  laboring,  and  allow  her 
to  collect  herself,  by  entering  into  conversation  with  her  upon  any  sub- 
ject foreign  to  her  situation.  Should  the  pains  come  on,  while  thus 
engaged,  if  they  are  of  trifling  importance,  the  practitioner  may  leave 
the  room,  or  occupy  himself  in  conversation  with  some  of  the  friends 
present,  and  especially  with  the  nurse,  from  whom  he  may  gain  infor- 
mation as  to  the  condition  of  the  bowels,  bladder,  and  previous  charac- 
ter of  the  pains.  But  if  the  pains  are  frequent  and  active,  or  occasion 
much  complaining,  he  may  then  inquire  of  the  patient,  herself,  in  a 
low  tone  of  voice,  relative  to  these  points ;  and  he  may  also  form  some 
idea  of  the  probable  advance  of  the  labor  from  the  character  of  the 
pains.  He  should  likewise  interrogate  as  to  the  general  health  of  the 
patient,  and  with  multipart,  the  character  of  previous  labors ;  ascer- 
tain the  present  condition  of  the  pulse,  skin,  and  tongue,  and  make 
such  other  inquiries  as  may  be  necessary. 

If  the  bowels  are  in  a  constipated  condition,  in  the  early  part  of  the 
first  stage  of  labor,  a  mild  cathartic  may  be  administered,  as  castor  oil, 
or,  whatever  unobjectionable  purgative  the  patient  may  prefer ;  but  if 
the  labor  has  advanced  to  nearly  the  commencement  of  the  second 
stage,  or  if  this  stage  is  already  present,  a  laxative  injection  should  be 
used  in  preference,  as  being  more  apt  to  cause  a  speedy  evacuation  of 
the  rectum.  And  at  all  times,  during  the  labor,  whenever  the  female 
desires  to  evacuate  the  bladder  or  rectum,  the  practitioner  should  leave 
the  room;  indeed,  it  is  proper  that- he  should  request  the  patient, 
through  the  nurse,  or  some  friend,  not  to  retain  these  discharges,  but 
to  have  him  notified,  whenever  they  are  called  for,  while  he  is  in  the 
room,  that  he  may  retire. 

As  soon  as  it  is  deemed  necessary  to  make  a  vaginal  examination, 
and  which  should  not  be  delayed  for  too  long  a  time,  the  request  must 
be  made  of  the  patient,  through  some  friend  or  the  nurse ;  the  object 
of  such  an  examination  is  usually  understood,  but  where  it  is  not,  an 
explanation  should  be  given,  stating  that  it  is  "  for  the  purpose  of 
learning  the  condition  of  the  parts,  the  manner  in  which  the  child  is 
coming,  and  to  know  that  everything  is  right  to  insure  a  safe  deliv- 
ery." Sometimes,  an  objection  is  made,  especially  by  those  in  their 
first  labors,  but  by  a  firm  and  gentle  course,  representing  to  the  patient, 


L;S,S  KIX<;'s    ECLECTIC    OBSTETRICS. 

that  her  own  safety,  as.  well  as  that  of  her  child,  may  depend  upon  an 
early  examination,  the  objections  will  generally  be  overcome.  Should 
the  female  be  pettish,  or  fidgety,  and  notwithstanding  these  represen- 
tations, persist  in  her  objections,  declaring  that  she  will  never  submit 
to  an  examination,  and  perhaps  using  harsh  words  to  the  physician,  all 
that  he  can  do,  will  be  to  wait  patiently  until  the  pains  have  subdued 
her  caprices  and  antipathies,  when  the  examination  will  be  cheerfully 
granted.  Generally  speaking,  however,  there  will  be  found  no  diffi- 
culty in  obtaining  the  consent  of  the  patient,  if  the  request  be  delicately 
made  through  a  third  (female)  person. 

One  other  reason  for  requiring  an  early  examination,  is,  that  the 
accoucheur  may  not  be  detained  for  hours,  waiting  upon  false  pains. 
I  have  known  several  young  practitioners,  who,  having  been  misled 
by  these  pains,  and  a  delicacy  as  to  insisting  upon  a  vaginal  examina- 
tion, have  been  deprived  of  their  rest  for  many  hours,  and  were  only 
made  aware  of  their  error,  when  the  loss  .of  confidence  in  their  abilities 
determined  the  patient  to  send  for  another  medical  man,  who  at  once 
explained  the  cause  of  the  delay.  Truly,  a  mortifying  situation  for 
any  one  to  be  placed  in!  Again,  it  may  be  the  case,  that  no  pregnancy 
exists. 

It  is  not  only  highly  proper,  but  it  is  a  positive  and  imperative  duty 
of  the  practitioner,  to  conduct  himself,  throughout  the  whole  course 
of  rjarturition,  with  firmness  and  kindness,  but  especially  with  de- 
corum, using  no  language,  arid  manifesting  no  actions  which  might 
offend  the  delicacy  or  modesty  of  the  most  fastidious.  It  will,  there- 
fore, be  proper  for  him  to  observe  the  persons  who  are  in  the  room, 
previous  to  making  an  examination,  prudently  dismissing  all  but  two 
or  three,  whose  presence  as  assistants  may  subsequently  be  needed ; 
and  unmarried  females  should  by  no  means  be  allowed  to  remain,  as 
they  can  render  but  little  assistance,  or  afford  but  a  small  share  of  con- 
solation to  the  patient.  The  presence  of  relatives  should  always  be 
preferred,  and  if  the  husband  remains  it  is  an  attention  which  many 
men  neglect  to  pay  to  their  wives  at  this  period,  and  should  be  rather 
encouraged  than  condemned;  his  presence  will  tend  to  check  the 
obscene  language  of  the  filthy-minded,  should  any  such  be  present. 
No  pure-minded  nor  well-meaning  practitioner  would  hesitate  for  a 
moment  to  perform  all  the  necessary  duties  of  his  profession  in  the 
presence  of  a  husband,  which  he  would  do  in  his  absence,  or  in  the 
presence  of  females.  £  servant  in  attendance,  to  do  the  errands  that 
may  be  requisite,  will  be  found  a  valuable  acquisition,  when  one  can 
be  had. 


MANAGEMENT  OF  NATURAL  LABOR.  289 

Previous  to  the  examination,  the  physician  must  see  that  the  nail  of 
the  finger  to  be  introduced  into  the  vagina  is  short,  otherwise,  it  might, 
by  coming  into  contact  with  the  tense  membranes,  at  this  early  period, 
rupture  them,  and  occasion  serious  results.  Indeed,  a  physician  with 
long  nails,  and  kept  in  a  state  of  uncleanliness,  is  not  a  very  proper 
nor  desirable  object  for  the  parturient  chamber.  Filthiness  of  person, 
in  any  respect,  implies  filthiness  or  carelessness  in  practice. 

There  are  various  positions  recommended  for  placing  the  female 
during  an  examination.  Sims'  position,  in  the  early  part  of  labor, 
is  the  preference  with  many ;  directing  the  patient  to  lie  on  the  bed, 
upon  her  left  side,  her  back  being  toward 'the  physician,  with  the 
hips  near  to  the  edge  of  the  bed,  and  the  knees  drawn  up  toward  the 
abdomen,  and  separated  a  little  by  a  pillow  or  cushion  placed  be- 
tween them.  Other  positions  may  be  advised,  as  to  lie  upon  the 
right  side,  or  upon  the  back,  in  which  case  the  right  or  left  hand 
may  have  to  be  used ;  but  an  accoucheur  should  accustom  himself  to 
examine  readily  with  either  hand.  I  usually  allow  the  patient  to 
take  the  position,  in  the  beginning,  that  seems; most  comfortable  to 
her.  I  find  it  more  convenient,  however,  if  she  remain  on  the  back, 
to  pass  the  hand,  in  making  the  examination,  beneath  the  flexed 
limb,  etc.  The  position  having  been  taken,  the  index  or  middle 
finger  is  to  be  annointed  with  lard,  sweet  oil,  pomatum,  or  other 
unctuous  substance,  both  for  the  purpose  of  an  easy  introduction  and 
that  the  parts  may  not  be  readily  irritated  by  its  presence,  as  well  as 
to  guard  against  the  contraction  of  disease,  should  any  be  present. 
A  cloth,  or  napkin,  .should  be  at  hand,  as  likewise  a  basin  of  water, 
soap,  and  towel,  for  the  subsequent  washing  of  the  hands.  In  all 
cases,  when  possible,  never  make  a  vaginal  examination  unless  in  the 
presence  of  a  third  person. 

Having  loosely  thrown  a  sheet  over  the  patient,  for  any  exposure  of 
her  person  is  unnecessary  and  reprehensible,  the  practitioner  will  seat 
himself  by  the  bedside  in  such  a  manner  as  will  admit  a  ready  intro- 
duction of  the  5nger  into  the  vagina,  that  is,  with  his  face  looking 
toward  the  head  of  the  patient,  and  his  side  to  the  side  of  the  bed  next 
the  patient.  As  simple  as  this  direction  may  be,  an  error  or  a  hesita- 
tion as  to  the  proper  mode  of  placing  the  chair,  may  destroy  the 
confidence  of  the  patient  or  her  friends.  During  the  presence  of  a 
pain  is  the  period  generally  advised  for  the  introduction  of  the  finger, 
hence,  it  is  frequently  termed  "taking  a  pain."  The  sheet  is  now  to 
be  raised,  but  without  any  exposure  of  the  female,  and  the  examining 
hand  of  the  accoucheur  passed  quickly  upward  toward  the  vagina;  the 
finger  is  to  be  carefully  and  slowly  introduced  along  the  posterior 
19 


KING'S     K(   I.KCTK'    OBSTETRICS. 

commissure,  and  into  the  vagina,  carrying  it  along  the  posterior  wall 
of  this  canal,  until  its  upper  extremity  is  reached ;  then,  by  bringing 
the  point  of  the  finger  toward  the  symphysis  pubis,  the  os  uteri  will  be 
felt.  The  practitioner  will  be  very  careful,  in  this  examination,  not  to 
introduce  his  finger  into  the  rectum  instead  of  the  vagina,  a  very 
mortifying  accident,  and  one  which  I  have  known  to  occur  in  the  early 
obstetric  practice  of  some  young  medical  gentlemen ;  it  will  not  be 
likely  to  happen,  if  presence  of  mind  is  retained,  with  a  freedom  from 
restraint  and  bashful  diffidence.  The  advice  to  envelop  the  arms  in  a 
towel,  or  cover  them  with  oil-silk  sleeves  at  this  early  examination,  is 
altogether  unnecessary. 

In  this  first  vaginal  examination,  there  are  several  conditions  to  be 
ascertained,  in  effecting  which,  the  physician  must  proceed  carefully 
and  cautiously,  and  without  undue  -haste;  nor  must  he  remove  his 
finger,  until  he  has  positively  satisfied  himself  in  relation  to  the  more 
important  symptoms.  A  great  fault  with  young  practitioners,  is  a 
species  of  delicacy  or  bashfulness,  which,  although  highly  commend- 
able, is  very  apt  to  prompt  them  to  make  a  hurried  and  unsatisfactory 
examination.  The  knowledge  to  be  acquired  is  :  1,  whether  pregnancy 
exists ;  2,  whether  the  woman  be  in  labor,  and  the  progress  it  has 
made ;  3,  which  is  the  presenting  part  of  the  child ;  4,  whether  the 
membranes  are  entire,  or  have  ruptured;  5,  the  condition  of  the  os 
uteri,  vagina,  perineum,  and  pelvic  diameters;  and  the  finger  should 
not  be  withdrawn  until  the  pain  has  passed  away,  and  a  sufficient  part 
of  the  succeeding  interval  has  been  occupied  in  making  the  examina- 
tion thorough  and  satisfactory. 

The  recommendation  to  ascertain  the  existence  of  pregnancy  in  a 
female  who  declares  herself  pregnant,  that  she  has  felt  the  motions  of 
the  child  very  sensibly,  and  that  she  is  suffering  from  labor-pains, 
may,  at  first  sight,  appear  rather  absurd,  but  when  we  reflect  that 
instances  have  not  unfrequently  occurred,  in  which  the  physician, 
misled  by  the  professions  of  the  woman,  who  was  herself  deceived  "in 
regard  to  her  condition,  has  remained  in  attendance  for  days  and  even 
weeks,  until  the  discovery  was  made  that  she  was  not  even  pregnant, 
rendered  him  the  mark  for  the  jest  and  ridicule  of  all  who  heard  of 
his  exploits;  this  caution  will  be  deemed  very  proper  and  essential. 
Many  circumstances  may  occasion  an  enlargement  of  the  abdomen,  as 
flatulency,  an  effusion  of  fluid  in  the  peritoneal  cavity,  tumors,  etc.; 
and  a  near  resemblance  to  labor-pains  may  be  occasioned  by  spasmodic 
action  of  different  muscles,  leading  the  female  to  believe,  not  only  that 
she  is  pregnant,  but  that  labor  has  actually  commenced.  It  will, 
therefore,  be  readily  understood,  that  the  accoucheur  can  place  no 


MANAGEMENT  OF  NATURAL  LABOR.  291 

reliance  upon  any  other  source  than  a  correct,  personal  examination. 
The  means  by  which  pregnancy  may  be  determined  have  already  been 
given  in  preceding  pages;  but  it  may  not  be  amiss  to  call  attention 
to  a  few  matters  relating  thereto.  In  many  instances,  the  hand  placed 
on  the  abdomen  for  the  purpose  of  detecting  the  contractions  of  the 
uterus  during  the  pains,  the  condition  of  the  abdomen  as  to  its  softness 
or  hardness,  and  elasticity,  the  extent  of  the  swelling,  and  its  shape, 
will  frequently  decide  the  question;  but  if  there  still  remains  am 
doubt,  the  vaginal  examination  will  be  more  likely  to  solve  it.  There 
will  be  found,  if  pregnancy  be  absent,  the  protruding,  unexpanded 
cervix,  with  a  close,  undeveloped  os  uteri,  and  the  uterus  when  poised 
on  the  end  of  the  finger,  will,  if  not  diseased,  be  found  small,  light, 
and  very  movable;  but,  if  pregnancy  be  present,  and  labor  com- 
mencing, the  cervix  will  be  found  expanded,  and  the  os  uteri  fully 
developed,  and  perhaps  sufficiently  open  to  allow  the  finger  to  enter, 
and  detect  the  presence  of  the  fetus.  When  doubt  still  remains,  bal- 
lottcment,  auscultation,  and  the  means  previously  recommended 
should  be  resorted  to. 

The  female  may  be  pregnant,  but  not  in  labor,  and  this  is  to  be 
determined  by  the  rules  given  in  the  previous  chapter.  This  is  a  point 
that  must,  as  well  as  the  preceding,  be  fully  solved,  or  else  the  prac- 
titioner may  subject  himself  to  much  ridicule  by  waiting  upon  "false 
pains"  instead  of  true  ones,  a  circumstance  which  has,  unfortunately, 
happened  more  than  once  in  practice.  Labor  may  be  detected  by  the 
true  pains  hardening  the  uterine  globe;  by  the  os  uteri  contracting 
during  the  presence  of  a  pain,  and  dilating  during  its  absence;  by  the 
bag  of  waters  being  tender,  tense,  and  protrusive  during  the  uteiine 
contractions,  and  becoming  soft  and  relaxed  in  their  absence,  receding 
within  the  uterine  cavity. 

During  the  presence  of  a  pain,  a  careful  examination  should  be  made 
to  ascertain  the  effect  produced  by  it  upon  the  os  uteri ;  whether  this 
is  high  up  in  the  pelvis,  or  low  down  :  whether  it  is  thick  or  thin, 
soft,  and  yielding,  or  thick,  rigid,  and  unyielding ;  and  in  doing  this, 
no  pressure  should  be  made  upon  the  membranes,  which  are  generally 
tense  and  thin  during  the  presence  of  pain,  lest  they  rupture,  and  a 
natural  labor  be  thereby  converted  into  a  protracted  one.  Upon  the 
cessation  of  the  pain,  as  soon  as  the  os  uteri  has  relaxed,  and  the  mem- 
branes have  collapsed,  and  not  before,  cautiously  introduce  the  finger 
within  the  orifice  of  the  os  uteri,  to  ascertain  whether  the  head  pre- 
sents, and  should  a  pain  come  on,  while  the  finger  is  within,  graduallv 
remove  it  as  the  membranes  protrude,  without  exerting  any  pressure 
upon  them,  and  re-introduce  it  on  the  subsidence  of  the  pain  and  col- 


29'2  KING'S   KCLKCTIC  OUSTKTHICS. 

lapse  of  the  membranes.  The  head  may  readily  be  known  by  its 
rounded  form,  its  peculiar  hardness,  and  its  sutures.  Tf  the  hard 
edges  of  the  parietal  bones  can  be  felt  along  the  sagittal  suture,  there 
can  be  no  difficulty  in  determining  the  presentation.  The  endeavor 
to  ascertain  the  position  of  the  head  at  the  commencement  of  labor, 
or  previous  to  the  rupture  of  the  membranes  and  completion  of  the 
first  stage,  is  unnecessary,  and  exceedingly  improper,  and  endangers 
the  rupture  of  the  membranes;  it  is  sufficient  to  know  positively  that  the 
head  presents,  and  this  information  should  always  be  obtained,  before 
withdrawing  the  finger,  for  it  quiets  any  fear  or  anxiety  on  the  part  of 
the  practitioner,  who  knows,  that  nature  is  most  generally  capable  of 
overcoming  or  rectifying  any  improper  positions  of  the  head  without 
artificial  interference.  "  Any  attempt  to  determine  in  which  of  the 
numerous  positions  described  by  some  authors,  the  head  is  placed  at 
the  brim  of  the  pelvis,  would  only  endanger  the  rupture  of  the  mem- 
branes, and  disturb  the  regular  order  observed  by  nature  in  the  process. 
Indeed,  I  can  not  discover  what  benefit  could  result  from  knowing 
during  the  first  stage  of  labor,  provided  you  can  touch  the  vertex  with 
the  point  of  the  finger,  in  which  of  the  six  or  eight  positions  of  Bau- 
delocque  and  other  foreign  authors,  the  head  is  placed,  The  import- 
ance attached  by  some  authors  to  a  knowledge  of  these  positions,  some 
of  which  are  wholly  imaginary,  has  probably  arisen  from  the  dangerous 
practice  of  employing  the  long  forceps  before  the  os  uteri  is  fully  dilated, 
and  before  the  head  has  passed  into  the  cavity  of  the  pelvis.  At  this 
early  stage  of  the  labor,  no  instrument  of  this  description  can  be  safely  used, 
and  if  the  operation  of  turning  were  required,  the  position  of  the  head 
would  have  no  influence  upon  the  method  we  would  adopt  in  turning. 
Be  sure  that  the  head  presents  before  you  state  this  to  the  nurse  or 
patient,  as  they  will  not  soon  forget  your  mistake,  if  it  should  turn 
out  to  be  a  case  of  nates  presentation." — Lee. 

Should  any  other  part  present  than  the  head,  the  practitioner,  has 
by  the  examination,  gained  information  which  will  enable  him  to  give 
the  necessary  assistance  at  the  proper  time ;  but  by  neglecting  to 
obtain  this  knowledge,  he  is  highly  culpable,  as  he  not  only  runs  the 
risk  of  exposing  his  patient  to  much  unnecessary  suffering,  but  may 
actually  endanger  her  life,  that  of  the  fetus,  or  the  lives  of  both.  The 
method  of  determining  face,  nates,  and  other  presentations,  together 
with  their  treatment,  will  be  described  hereafter.  I  may  state  here, 
that  if  the  index  finger  fails  to  reach  the  os  uteri,  or  feel  the  present- 
ing part,  two  fingers,  the  index  and  middle,  should  then  be  introduced, 
for  it  is  imperative  that  the  practitioner  should  decide  the  presentation 
at  as  early  a  period  as  possible.  It  is  frequently  the  case,  especially  in 


MANAGEMENT  OP  NATURAL  LABOR.  293 

females  of  irritable  habits,  that  the  most  cautious  introduction  of  the 
finger  within  the  os  uteri  will  occasion  the  uterus  to  contract ;  and  in 
nearly  all  patients,  the  excitement  produced  by  the  finger  being  need- 
lessly moved  round  to  discover  the  position  of  the  presenting  part,  will 
induce  contractions,  which  may,  more  or  less  suddenly,  force  the  mem- 
branes against  the  finger  and  rupture  them,  occasioning  a  premature 
dischage  of  the  liquor  amnii,  an  accident  always  to  be  dreaded  in  the 
early  part  of  the  first  stage  of  labor.  When  the  membranes  are. entire, 
the  protruding  bag  of  waters  will  be  felt  during  the  pain,  and  there 
will  be  no  dribbling  away  of  the  liquor  amnii ;  if  they  be  ruptured, 
the  presenting  part  can  be  more  readily  detected,  the  hairy  scalp  puck- 
ering up  during  the  pain,  and  becoming  smooth  and  even,  when  it 
subsides ;  while,  on  the  contrary,  the  membranes  are  smooth  and  tense 
while  the  pain  is  on,  and  lax  during  its  absence. 

The  finger  being  withdrawn  from  the  os  uteri,  the  dimensions  of  the 
pelvis  and  its  conditions,  should  then  be  explored,  for  the  purpose  of 
determining  the  probable  character  of  the  labor.  The  point  of  the 
finger  should  be  carried  toward  the  promontory  of  the  sacrum,  as  ex- 
plained when  describing  the  pelvic  diameters,  and  if  this  be  not 
touched,  the  space  is  ample  enough  for  the  passage  of  the  fetus,  and  if 
deemed  necessary,  the  other  diameters  may  be  ascertained  by  the  rules 
heretofore  given.  The  condition  of  the  soft  parts,  as  to  whether  they 
are  hot  or  normally  cool,  dry  or  moist,  soft  and  yielding,  or  hard  and 
unyielding,  should  also  be  observed — the  finger  should  then  be  with- 
drawn, wiping  it  with  a  napkin,  while  still  under  the  sheet;  after 
which,  the  hands  may  be  washed. 

As  soon  as  the  examination  is  finished,  the  patient  and  her  friends, 
being  naturally  anxious  to  know  whether  everything  is  right,  will 
interrogate  the  physician  relative  thereto.  This  is  a  very  delicate 
position  for  him  to  be  placed  in,  for  if  the  reply,  or  opinion  expressed, 
prove  incorrect,  the  confidence  which  the  parties  repose  in  him,  will  be  at 
once  lessened  or  altogether  .destroyed,  and  another  physician  may  be 
sent  for ;  beside  which,  it  may  give  rise  to  some  apprehensions  on  their 
part,  that  difficulty  or  danger  in  the  case  exists,  not  recognized  by  the 
medical  attendant.  Consequently,  a  reply  to  such  interrogations 
should  be  very  guarded ;  the  physician  should  never  permit  himself  to 
be  betrayed  into  the  expression  of  a  positive  opinion  on  this  subject. 
When  the  head  presents,  and  everything  appears  to  be  in  a  favorable 
condition,  he  may  state  this,  and  add,  that  if  no  unforeseen  circum- 
stances occur,  and  the  labor  progresses  uninterruptedly,  she  will,  prob- 
ably, be  delivered  by  such  a  time,  naming  the  longest  possible  time 
suggested  by  the  examination ;  and  if  delivery  is  eifected  previous  to 


294  KI.\<;'s    KCLKCTIC    OBSTKTUK'S. 

this  time,  it  will  prove  anything  but  a  disappointment  to  the  patient,, 
and  will  occasion  no  doubt  of  the  accoucheur's  skill  or  acquaintance 
with  his  profession.  The  reasons  for  such  a  course  are  sufficiently 
obvious ;  for  it  frequently  happens  that  a  labor  which  commences 
rapidly  and  with  a  prospect  of  speedy  termination,  becomes  protracted 
during  its  latter  part ;  and  one  that  has  a  slow  and  tedious  beginning, 
may  advance  with  rapidity  during  the  second  stage ;  Reside,  many  cir- 
cumstances may  transpire  during  the  progress  of  labor,  which  may 
convert  it  into  one  of  a  protracted  and  even  dangerous  character.  By 
remembering  the  following  points,  which  have  been  laid  down  by 
accoucheurs,  a  pretty  accurate  estimate  as  to  the  duration  of  labor  may 
be  formed,  when  not  interfered  with  by  unexpected  accidents  : 

1.  First  labors  are  commonly  more  tedious  than  subsequent  ones. 

2.  Labor    advances   more    rapidly   where   the   pelvis   is   of  large 
dimensions  than  where  it  is  small. 

3.  In  proportion  to  the  softness  and  yielding  of  the  soft  parts,  will 
be  the  rapidity  of  the  labor. 

4.  The  duration  of  labor  is  always  modified  by  the  character  of  the 
pains. 

5.  Labor  will  be  accomplished  at  an  earlier  period  when  the  os  uteri 
is  dilated,  or  thick,  soft,  and  dilatable,  than  when  it  is  thin  and  firm, 
even  though  somewhat  dilated. 

6.  A  soft  and  slightly  dilated  os  uteri,  moist  and  relaxed  condition 
of  the  soft  parts,  and  regularity  in  the  pains,  are  signs  of  a  speedy 
delivery.     When  these   symptoms  are   present,  and   the   os   uteri  is 
dilated  to  a  size  corresponding  in  diameter  to  that  of  half  a  dollar, 
most  accoucheurs  consider  it  improper  to  leave  the  patient,  especially 
if  it  be  in  the  night — and  which  will  be  found  a  good  general  rule  to 
adopt  in  practice. 

7.  Labor  will  be  rapid  where  the    vagina   is   large   and   yielding 
throughout  its  whole  extent;  but  will  be  slow  where  it  is  small  and 
unyielding.     "  If  the  entrance  of  the  vagina  is  small,  the  neighboring 
parts  cool,  dry,  inelastic,  and  as  if  tightly  drawn  over  the  bones ;  if 
the  finger,  in  spite  of  being  well  oiled  and  carefully  introduced,  pro- 
duces pain  upon  the  gentlest  attempt  to  examine,  we  may  expect  a 
tedious  and  difficult  labor." 

8.  When  the  upper  portion  of  the  vagina  is  well  dilated,  and  its 
lower  portion  is  rigid  and  contracted,  the  labor  will  be  rapid  during 
its  first  half  and  protracted  afterward;  and  vice  versa. 

9.  Labor  is  almost  always  tedious  in  primiparse  of  advanced  years. 
10.  Notwithstanding  all  the  above  points,  unexpected  changes  may 

occur  which  will  materially  alter  the  character  of  the  labor,  and  hence 


MANAGEMENT  OF  NATURAL  LABOR.  295 

the  necessity  of  expressing  an  opinion,  as  to  the  duration  of  labor, 
with  a  cautious  reserve;  for  "no  one  can  know  beforehand,  when  a 
labor  shall  be  terminated,"  and  no  good  practitioner  ever  makes  prog- 
nostics. Should  the  examination,  at  any  time  during  the  first  stage  of 
labor,  discover  rigidity  of  the  parts,  it  must  be  treated  as  described 
under  difficult  or  protracted  labor.  If  the  breech,  an  arm,  or  any  other 
unusual  part  presents,  it  should  be  made  known  to  the  nurse,  or  some 
friend,  but  not  to  the  patient,  and  the  proper  means  should  be  pursued, 
as  hereafter  laid  down. 

The  examination  being  over,  the  condition  _of  the  patient's  bowels 
and  bladder  must  be  attended  to,  if  this  has  not  been  done  previously, 
using  the  catheter  to  evacuate  this  latter  organ  if  required ;  and  it 
must  be  recollected,  that  these  are  essential  and  necessary  measures  to 
insure  a  safe  and  speedy  delivery.  Now  is  also  the  time  to  make  the 
proper  arrangements  for  the  delivery,  as  preparing  the  bed,  and  getting 
in  readiness  the  ligatures,  scissors,  bandage,  etc.;  an  attention  to  these 
little  but  very  necessary  matters,  serves  to  secure  the  confidence  of  the 
patient  and  her  friends,  a  very  important  desideratum  in  obstetric 
practice.  The  adjustment  of  the  bed  is  usually  attended  to  by  the 
nurse,  still  it  is  requisite  for  the  practitioner  to  understand  the  method 
of  doing  it,  as  he  will  frequently  be  called  upon  to  give  directions  in 
relation  thereto.  A  cot,  hair  mattress,  or  straw  mattress  may  be  used, 
but  by  no  means  a  feather  bed;  and,  if  the  patient  have  but  the  one 
feather  bed,  it  must  be  removed  or  rolled  to  one  side,  that  the  under 
mattress  may  be  used  for  her  to  lie  upon.  OveV  this  a  folded  sheet, 
blanket,  or  any  soft  material,  to  protect  the  mattress  or  cot  from  the 
discharges,  must  be  placed,  covering  that  part  of  it  which  will  be 
occupied  by  the  .patient's  hips.  During  the  second  stage  of  labor, 
some  recommend  a  piece  of  oil-cloth,  or  leather,  or  india-rubber 
cloth — these  are  all  proper,  but  are  not  always  at  hand.  Upon  the 
folded  blanket,  or  material  that  is  employed,  ,the  sheet  upon  which  the 
patient  is  to  Lie,  maybe  placed.  Care  must  be  taken  that  in  preparing 
or  guarding  the  bed,  as  it  is  sometimes  called,  no  depressions  or  con- 
cavities are  formed,  into  which  the  pelvis  might  sink  down;  at  this 
point  it  should  rather  be  elevated  a  little.  Thus  arranged,  the  bed  is 
ready  for  the  delivery  when  it  comes  on. 

A  piece  of  narrow  tape,  or  bobbin,  or  linen  thread  doubled,  two  or 
three  times,  and  a  few  inches  in  length,  must  be  secured  for  a  ligature. 
I  generally  use  two  ligatures,  and  which,  together  with  a  pair  of 
sharp  scissors,  should  be  placed  in  a  convenient  position  for  the  prac- 
titioner to  reach,  when  it  becomes  necessary  to  ligature  the  umbilical 
cord  and  divide  it;  or  these  may  be  handed  to  him  by  one  of  the 


296  KIN(;'S    I-X 'LECTIO    OBSTETRICS. 

female  assistants.  Long  and  strong  pins  should  also  be  held  in  readi- 
ness, with  which  to  pin  the  binder  or  bandage,  after  the  delivery ; 
but  it  will  often  be  found  that  the  female  has  a  binder  already  made 
which  requires  to  be  fastened  and  retained  with  a  cord,  like  a  corset 
but  these  are  generally  troublesome  and  in  the  way,  and  I  do  not  like 
them  as  well  as  a  good  stout  towel,  or  piece  of  unbleached  muslin, 
about  a  foot  wide,  and  three  or  four  feet  long. 

The  room  must  be  kept  comfortably  cool,  and  free  from  unpleasant 
odors,  the  clothing  of  the  patient  should  be  light  and  loose,  and  the 
diet,  if  any  is  required,  composed  of  crackers,  gruel,  toast-water,  tea, 
and  cold  water;  no  stimulating  articles  of  food  or  drink,  nor  meats 
should  be  allowed,  nor  should  any  solicitations  be  used  to  induce  an 
appetite. 

Everything  having  been  thus  attended  to  and  prepared,  nothing 
else  can  be  done  than  to  wait  patiently  for  the  second  stage  of  labor ; 
the  practitioner  can  do  nothing  to  facilitate  the  progress  of  the  first 
stage,  and  any  interference  to  dilate  the  os  uteri,  or  passages  through 
which  the  child  has  to  be  expelled,  or  in  any  other  way  to  hasten  the 
labor,  is  a  mark  of  ignorance,  and  is  fraught  with  serious  consequences. 
Even  the  too  frequent  repetition  of  the  vaginal  examination  is  im- 
proper ;  probably,  another  examination  may  not  be  required  for  an 
hour  or  two,  but  this  will  depend  very  much  upon  the  increased 
strength  and  frequency  of  the  pains,  as  well  as  the  capaciousness  of 
the  pelvis,  and  the  yielding  character  of  the  soft  parts.  It  is  proper 
to  examine  the  hypogastrium  occasionally  to  be  certain  that  the  bladder 
does  not  become  distended  with  urine,  and  this  may  be  done  at  the 
time  of  the  vaginal  examinations ;  during  a  protracted  labor,  an  atten- 
tion to  this  circumstance  is  very  important,  that  the  catheter  may  be 
used  without  delay,  as  soon  as  a  necessity  for  it  arises. 

In  reference  to  the  condition  of  the  bladder,  the  accoucheur  should 
always  personally  satisfy  himself,  for  it  often  happens  that  he  will 
be  told  the  urine  passes  freely,  when,  in  fact,  there  is  only  a  mere 
dribbling  of  fluid  upon  the  recurrence  of  each  uterine  contraction,  and 
which  may  be  the  liquor  amnii,  or  a  portion  of  urine  forced  out  of  the 
bladder  in  consequence  of  its  contraction  by  the  abdominal  muscles  ; 
this  latter  circumstance  is  an  indication  that  the  bladder  contains  a 
large  amount  of  fluid,  which  requires  an  artificial  evacuation.  In 
introducing  the  catheter,  the  index  finger  of  the  left  hand  is  to  be 
passed  between  the  labia  majora,  and  carried  toward  the  vestibulum, 
at  the  lower  part  of  which,  just  within  the  lower  angle  of  the  pubic 
symphysis,  the  meatus  urinarius  may  be  detected  by  a  slight  pressure 
of  the  finger  upon  this  part ;  the  point  of  the  catheter  should  then  be 


MANAGEMENT    OF     NATURAL    LABOR.  297 

passed  along  the  inner  surface  of  the  finger,  until  it  reaches  the 
urethra]  orifice,  when  a  slight  movement  will  cause  it  to  enter.  It 
should  be  passed  upward  without  force,  until  about  three-fourths 
of  it  has  entered,  being  careful  not  to  allow  it  to  slip  entirely  into  the 
bladder ;  some  small  vessel  must  be  in  readiness  to  receive  the  urine 
as  it  passes.  When  the  pelvis  is  occupied  by  the  head,  a  flat  catheter 
will  be  preferable  to  a  round  one,  as  it  does  not  take  up  so  much  space 
in  the  antero-posterior  diameter.  Sometimes  the  introduction  of  the 
instrument  into  the  bladder  will  be  facilitated  by  gently  raising  the 
head  of  the  child,  during  the  absence  of  uterine  contraction. 

Some  time  may  elapse  before  the  commencement  of  the  second 
stage  of  labor,  and  a  few  suggestions  relative  to  the  mode  of  employ- 
ing the  time,  may  be  of  service,  especially  to  the  young  accoucheur. 
If  the  labor  has  just  commenced,  and  everything  is  found  right  on 
examination,  there  will  be  no  necessity  for  tarrying  at  the  house;  the 
practitioner  may  return  home,  or  visit  other  patients,  being  careful  not 
to  allow  his  absence  to  exceed  one  hour,  as  it  may  then  become 
necessary  to  institute  another  vaginal  exploration.  Much,  however, 
will  depend  upon  circumstances;  if  it  be  a  first  labor,  it  will  not, 
probably,  progress  very  rapidly ;  if  previous  labors  have  been  rapid, 
too  long  an  absence,  from  the  patient  is  not  advisable,  and  more 
especially  when  the  os  uteri  is  dilated  to  nearly  the  size  of  half  a 
dollar,  or  is  very  soft  and  dilatable ;  for  it  must  be  remembered,  that 
although  it  may  have  required  several  hours  to  obtain  the  above 
degree  of  dilatation,  the  remainder  of  the  process  may  be  effected  in  a 
very  short  time,  and  labor  be  completed  by  only  a  few  more  pains. 
Should  the  physician  conclude  to  remain  with  the  patient  during  the 
first  stage  of  labor,  and  which  is  the  course  usually  pursued  when  the 
visit  is  late  at  night,  it  is  not  proper  that  he  should  continue  all  the 
time  in  the  parturient  chamber,  as  it  may  prevent  his  patient  from 
attending  to  the  fecal  and  urinary  discharges,  the  calls  to  one  or  both 
of  which  are  apt  to  be  rather  frequent.  He  should  retire  to  some 
other  room,  generally,  if  possible,  so  situated  that  he  can  hear  the 
cries  of  the  female,  and  thus  be  able  to  determine  the  progress  of  the 
labor,  as  well  as  the  necessity  for  another  examination.  Or,  if  this  can 
not  be  done,  the  room  not  being  favorably  situated  for  the  purpose, 
he  will  request  the  nurse  to,  inform  him,  from  time  to  time,  of  the 
advance  of  the  pains,  their  frequency  and  strength.  While  thus 
absented  in  another  room,  he  may  employ  himself  in  reading,  in  con- 
versation, etc.,  but  should  never  permit  himself  to  become  so  far 
interested  in  whatever  employment  he  adopts,  as,  for  a  moment,  to 
.forget  his  patient.  Or,  if  there  is  a  probability  that  the  labor  may 


'2V$  KINti's    ECLECTIC    OBSTETRICS. 

not  require  his  immediate  attention  for  a  few  hours,  he  may  lie  down 
on  a  sola  or  bed,  and  enjoy  ;i  short  sleep,  until  the  nurse  awakens 
him,  at  such  time  as  he  may  have  requested.  If  there  is  but  one  room 
occupied  by  the  family,  as  is  frequently  the  case  with  the  poorer 
classes,  it  will  be  proper  for  him  to  leave  it  occasionally  to  take  a  peep 
at  the  stars,  or  a  glance  at  the  weather,  or  to  inhale  a  little  fresh  air, 
for  the  purpose  of  relieving  a  little  dullness  of  feeling,  etc.,  remarking 
as  he  goes  out,  that  he  will  return  in  ten  or  twelve  minutes ;  thus 
giving  the  female  an  opportunity  to  attend  to  her  evacuations.  These 
little  attentions,  and  especially  if  performed  wiih  a  degree  of  delicacy, 
will  always  produce  a  favorable  impression,  which  may  subsequently 
prove  advantageous  to  the  physician. 

"While  in  the  room  with  the  patient,  it  is  always  proper  to  speak 
encouragingly  to  her,  and  endeavor  to  cheer  her  up,  occasionally 
assuring  her  when  such  is  really  the  case,  that  everything  is  going 
right.  But,  above  all  things,  avoid  that  very  reprehensible  and 
demoralizing  practice,  which  is  too  common  among  some  persons, 
of  indulging  in  filthy  and  obscene  convei'sation ;  some  individuals, 
and  among  them  I  regret  to  say  are  found  females,  seem  to  select  this 
as  the  best  time  for  the  delivery  of  all  the  obscenity  with  which  their 
minds  are  filled,  and  vie  with  each  other  as  to  who  shall  bear  off  the 
palm  in  such  disgusting  loquaciousness.  This  kind  of  chat  has  a 
depressing  and  injurious  influence  upon  the  patient,  beside  polluting 
the  minds  of  all  present ;  and  I  have  no  doubt,  but  that  the  first 
approach  toward  a  departure  from  virtue,  has,  with  many  females, 
commenced  in  the  parturient  room,  where  these  coarse  and  indelicate 
conversations  were  permitted.  No  gentleman,  and  certainly  no  lady, 
would  be  guilty  of  such  low  and  undignified  behavior.  It  is  the  duty 
of  the  physician,  at  all  times,  and  under  all  circumstances,  not  only 
to  preserve  and  protect  the  health  of  his  patient,  but  likewise  to 
preserve  and  protect  the  purity  of  her  mind,  and  any  one  who  pursues 
a  different  course,  should  not  be  recognized  as  a  professional  brother 
nor  as  a  man  worthy  the  confidence  of  community. 

It  is  not  necessary,  during  the  first  stage  of  labor,  that  the  female 
should  retain  the  recumbent  position,  she  may  sit  up,  walk  about,  lie 
down,  and  change  her  position,  according  to  her  inclination ;  nor 
should  any  bearing-down  efforts  be  permitted  during  this  stage,  as 
they  exhaust  the  patient's  strength,  without  effecting  the  least  benefit 
whatever,  and  may  also  cause  a  premature  rupture  of  the  membranes, 
and  thus  convert  the  labor  into  a  difficult  one.  It  is  onlv  when  the 


MANAGEMENT  OF  NATURAL,  LABOR.  299 

os  uteri  is  fully  dilated,  and  the  membranes  have  ruptured,  that  she 
must  assume  the  recumbent  position,  or  make  use  of  any  voluntary 
efforts  at  bearing  down. 

After  the  full  dilatation  of  the  os  uteri,  until  the  birth  of  the  child, 
the  female  should  be  required  to  remain  in  the  recumbent  position, 
lest,  while  moving  about,  the  child  should  suddenly  be  expelled  upon 
the  floor,  and  the  uterus,  following  the  cord  and  placenta,  become 
inverted.  But,  in  a  prolonged  labor,  where  there  is  no  immediate 
danger  of  rapid  expulsion,  she  may  be  permitted  to  sit  up  at  short 
intervals,  as  well  as  to  change  her  position  on  the  bed.  If,  at  the 
complete  dilatation  of  the  os  uteri,  the  membranes  have  not  ruptured, 
the  head  presenting,  and  the  soft  parts  being  yielding,  the  accoucheur 
should  rupture  them ;  but  not  under  other  circumstances,  except  those 
referred  to  hereafter.  Sometimes,  the  head  emerges  from  the  vulva 
.simultaneously  with  the  rupture  of  the  membranes,  but  this  most 
commonly  occurs  in  cases  where  the  membranes  are  unusually  tough, 
and  have  been  allowed  to  remain  entire  until  the  head  has  cleared  the 
os  uteri  and  advanced  considerably  into  the  pelvic  cavity. 

During  the  second  stage  of  labor,  many  practitioners  pass  a  towel 
around  each  fore-arm,  without  removing  the  coat,  as  a  protection 
against  the  discharges.  The  towel  is  doubled  so  as  to  form  a  triangle, 
the  base,  or  folded  edge  of  which,  is  passed  rather  tightly  around  the 
wrist,  but  not  so  as  to  interfere  with  its  free  motion,  the  rest  being 
folded  with  one  end  over  the  other,  around  the  arm,  and  then  pinned, 
and  which  is  usually  done  by  some  female  present.  Others,  again, 
have  oil-silk  sleeves  for  the  purpose  which  they  draw  on  over  the  coat 
sleeves.  Some,  merely  remove  the  coat,  and  roll  up  the  shirt  sleeves^ 
thus  having  a  free,  unimpeded  use  of  the  hand  and  arms,  especially  in 
cases  where  manual  assistance  is  required.  This  latter  plan  is  the 
one  which  I  prefer;  but  the  accoucheur  may  please  himself  in  these 
respects. 

After  the  rupture  of  the  membranes,  the  practitioner  should  make 
no  delay  in  ascertaining  the  position  of  tho  presentation ;  and  an  early 
examination,  at  this  time,  is  often  of  much  importance,  as  any  mal- 
position may  be  more  readily  rectified  than  at  a  later  period.  The 
situation  of  the  head  at  the  time  of  tho  rupture  varies;  most  com- 
monly it  will  be  found  just  within  the  brim,  sometimes  midway  in  the 
pelvic  cavity,  or  at  the  perineum,  etc.  The  position  of  the  head  may 
be  determined  by  the  rules  heretofore  named.  During  this  stage 
of  labor,  the  patient  should  not  be  left  by  her  medical  attendant, 
who  will  find  it  necessary  to  repeat  his  examinations  every  four,  six. 


300  KIND'S    KCI.KCTIC   nnsTKTKlrs. 

or.  eight  pains,  according  to  their  frequency  and  strength,  and  the 
rapidity  with  which  the  head  advances;  and  after  these  examinations, 
it  is  not  necessary  to  wash  the  hands  each  time,  but  merely  to  dry 
them  on  a  napkin,  secured  for  the  purpose.  It  is  also  an  excellent 
plan  for  the  accoucheur,  by  means  of  a  flexible  stethoscope,  to  examine 
the  condition  of  the  fetal  heart  from  time  to  time,  both  during  natural 
and  unnatural  labors,  as  the  information  thus  acquired  may  prove 
of  great  value  in  the  management  of  the  case,  and  save  his  patient 
much  suffering  and  danger.  Should  the  patient  suffer  from  cramps 
of  the  lower  extremities,  they  may  be  removed  by  frictions  with  the 
hand  over  the  part  affected,  or  ligatures  around  it,  or  warm  applica- 
tions; pain  in  the  sacrum,  occasioned  by  pressure  of  the  presenting 
part  upon  the  anterior  sacral  nerves,  may  be  relieved  by  firm,  counter- 
pressure  against  the  posterior  face  of  the  sacrum,  during  a  pain,  and 
which  should  be  made  by  the  nurse,  or  some  female  present;  the 
practitioner  should  avoid  any  fatiguing  exercise,  or  manipulation, 
unless  when  imperatively  required.  If,  however,  the  pain  should  be 
very  severe,  and  no  relief  be  afforded  by  the  counter-pressure,  and 
the  efficiency  of  the  pains  be,  at  the  same  time,  diminished,  it  may 
become  necessary  to  relieve  the  agony  of  the  patient,  by  hastening  the 
delivery  with  the  forceps.  I  have  heard  of  a  Professor  of  Obstetrics, 
who  informed  his  class,  that  he  had  relieved  several  instances  of  this 
kind,  by  placing  a  folded  handkerchief  between  the  head  and  the 
nerves.  But  it  must*  be  remembered,  that  this  would  still  further 
diminish  the  diameter  of  the  pelvic  cavity,  and  be  very  apt  to  produce 
irritation,  dryness,  and  probable  inflammation  of  the  parts;  perhaps 
the  Professor  may  have  dreamed  of  these  several  cases,  and  forgotten 
that  they  were  but  dreams. 

The  position  which  I  prefer  for  the  delivery,  is  on  the  back,  having 
the  knees  flexed  toward  the  abdomen,  and  the  feet  resting  against  some 
support,  as  the  footboard  of  the  bed  ;  and  a  sheet  or  towel  fastened  to 
the  bedpost,  may  he  held  by  the  patient,  upon  which  she  may  pull 
during  the  presence  of  the  pain,  or  the  hand  of  an  attendant  may  be 
used.  In  this  stage,  the  auxiliary  aid  of  the  diaphragm  and  abdomi- 
nal muscles  are  useful,  and  the  patient  may  be  advised  to  make  bearing- 
down  efforts,  when  the  pain  is  on.  Her  dress  should  be  so  far  drawn 
up  underneath  her,  as  to  prevent  it  from  being  soiled  by  the  discharges. 
And  until  the  period  when  the  head  presses  upon  the  perineum,  it  is 
not  necessary  for  her  to  remain  in  one  position  all  the  time,  though 
she  must  not  be  allowed  to  get  out  of  the  bed.  It  is  during  this  stage, 
that  many  practitioners  have  applied  an  obstetrical  supporter.  As  a 


MANAGEMENT  OF  NATURAL  LABOR.  301 

general  thing,  supporters  have  notfbeen  found  so  useful  in  practice  a& 
was  at  first  supposed,  and  are  seldom,  if  ever,  made  use  of  by  the 
obstetrician. 

Various  other  positions  for  delivery,  are  recommended  by  writers, 
and  assumed  by  females ;  as  sitting,  kneeling,  leaning  over  a  chair,  and 
lying  on  the  left  side.  Females,  generally,  will  assume  the  position 
recommended  by  the  physician,  but  where  they  obstinately  prefer  a  cer- 
tain position,  and  it  is  immaterial,  so  far  so  the  delivery  is  concerned, 
it  is  better  to  allow  them  their  own  way.  Lying  upon  the  left  side, 
with  the  knees  flexed,  and  a  pillow  placed  between  them,  is  the  posi- 
tion most  generally  recommended  in  this  country  and  England;  but  I 
do  not  think  that  the  delivery  proceeds  with  so  much  ease  and  rapidity, 
nor  it  so  convenient  for  the  practitioner  in  every  respect,  as  when  the 
female  is  placed  upon  the  back.  Some  writers  maintain,  that  the 
action  of  the  uterus  is  frequently  interfered  with,  and  the  progress  of 
labor  impeded,  when  the  female  lies  on  her  left  side,  in  consequence 
of  an  obliquity  of  the  uterus,  caused  by  this  position ;  also,  that  the 
too  close  condition  of  the  limbs,  produced  thereby,  retards  the  labor, 
and  to  overcome  which  the  advocates  of  this  position,  advise  a  pillow 
to  be  placed  between  them,  which  causes  much  unnecessary  heat. 
When  lying  upon  the  back,  the  limbs  can  be  kept  apart  with  ease,  the 
axis  of  the  uterus  is  brought  into  a  favorable  direction  'for  an  easy 
delivery,  and  the  patient,  being  in  a  position  requiring  no  muscular 
exertion  to  maintain,  can  freely  and  more  powerfully  employ  the 
abdominal  muscles. 

"When  the  head  has  reached  the  perineum,  the  practitioner  will  take 
his  seat,  by  the  bedside,  in  the  position  heretofore  named,  and  as  the 
part  begins  to  distend,  he  should  keep  his  finger  gently  upon  the  head, 
during  each  pain,  so  as  to  ascertain  the  proper  period  for  supporting 
the  perineum,  in  order  to  protect  it  from  becoming  lacerated,  and  the 
advance  of  the  head  must  be  determined,  not  by  its  condition  at  the 
pubic  arch,  but  at  the  perineum.  As  soon  as  the  perineum  is  fully  dis- 
tended and  protruding,  and  the  head  about  emerging,  and  not  before,  a 
folded  cloth,  or  napkin,  light  and  not  too  thick  or  bulky,  may  be 
placed  over  it,  extending  from  its  anterior  edge  to  the  coccyx,  and 
which  must  be  sustained  by  either  hand,  as  the  case  may  require,  more 
commonly  the  right.  The  pressure,  made  in  giving  support  to  the  peri- 
neum, must  be  moderate,  it  must  not  interfere  with  the  advance  of  the 
head,  the  part  requiring  firmer  support  toward  the  coccyx  than  at  its 
anterior  edge ;  and  instead  of  making  efforts  to  retract  the  skin  over 
the  head,  as  it  passes  through  the  orifice,  the  perineum  and  the  head 


: JOl'  KIN<,'s    KCLECTIC    OBSTHTHK  S. 

ghould  be  carried  upward  and  forward  in  the  direction  of  the  axis  of 
tlie  inferior  strait;  this  action  would  press  the  fetal  head  toward  the 
pubic  arch,  and  tend  to  elongate  the  perineum  forward ly,  thereby 
diminishing  the  risk  of  laceration,  by  facilitating  the  movement  of 
extension  of  the  fetal  head.  This  pressure  should  not  be  long  contin- 
ued, nor  should  it  be  made  at  all,  except  when  the  pain  is  present,  an.1 
it  would  be  much  better  to  leave  the  part  entirely  untouched,  than  t< 
make  improper  pressure,  which  has  frequently,  of  itself,  occasioned  tht 
very  difficulty  it  was  intended  to  obviate.  There  is  scarcely  any 
necessity  for  this  support  when  the  perineum  is  gradually  yielding  to 
the  normal  advance  of  the  fetal  head ;  .but  when  the  head  is  rapidly 
advancing,  the  perineal  tissues  not  being  sufficiently  softened,  support 
of  this  kind  may  prevent  laceration  ;  and  it  may  also  be  useful  in 
oases  of  delivery  by  the  forceps.  Some  authors  advise  to  support  by 
pressing  the  bare  thumb  upon  the  anterior  edge  of  the  perineum,  while 
the  index  and  second  finger  rest  upon  the  vertex  to  check  its  too  rapid 
advance ;  this,  to  my  mind,  is  equal  to  no  support  at  all,  the  object  of 
support  being,  in  my  opinion,  to  elongate,  as  it  were,  and  aid  in  the 
relaxation  of  the  perineum,  and  at  the  same  time  to  press  the  occiput 
against  the  pubic  arch  and  facilitate  the  movement  of  extension. ' 

My  experience  in  this  matter,  leads  me  to  believe,  that  laceration  of 
the  perineum  would  be  a  rare  accident,  were  the  rule  to  support  it 
during  the  latter  part  of  the  second  stage  of  a  normal  labor,  entirely 
dispensed  with  in  obstetrical  practice.  Some  writers  recommend  the 
support  of  the  perineum,  not  only  during  the  passage  of  the  head,  but 
likewise  of  that  of  the  shoulders,  from  a  belief  that  the  perineum  is 
frequently  lacerated  as  the  bis-acromial  diameter  is  emerging ;  in  some 
instances,  an  attention  to  this  point  may  prove  serviceable,  but  I  do  not 
regard  it  necessary  as  a  general  rule. 

While  the  head  is  at  the  perineum,  pressing  upon  the  lower  part  of 
the  rectum,  a  great  disposition  to  evacuate  the  bowels  will  be  produced, 
and  the  female  will  desire  to  rise  and  attend  to  the  call ;  but  it  must 
by  no  means  be  granted,  as  a  violent  pain  might  come  on,  and  the 
child  be  delivered,  and  perhaps,  destroyed,  before  the  physician  could 
bestow  the  necessary  attention.  Beside,  these  desires  generally  dis- 
appear with  the  delivery  of  the  head,  the  pressure  of  which  upon  the 
parts  has  occasioned  the  tenesmus.  I  have  twice  witnessed  the  delivery 
of  the  child,  and  its  reception  into  the  chamber-utensil,  where  the  physi- 
cians had  permitted  the  females  to  attempt  an  evacuation  of  the  rectum, 
at  this  stage  of  the  labor.  Again :  should  the  bowels  not  have  been 
opened,  early  in  the  labor,  and  the  probability  is,  that  a  fecal  discharge 


MANAGEMENT  OF  NATURAL,  LABOR.  303 

may  happen,  the  patient  must  not  be  permitted  to  rise  from  the  bed, 
but  must  perform  the  evacuation  on  some  old,  useless  cloths,  to  be 
placed  under  her  for  such  purpose,  and  which  are  then  to  be  immedi- 
ately removed. 

It  is  sometimes  the  case,  that  the  pains  cease,  or  diminish  in  strength, 
toward  the  close  of  the  second  stage,  but  they  may  be  renewed  by 
making  firm  pressure  with  the  left  hand,  upon  the  uterus,  each  time 
of  its  contracting,  or,  by  pressing  firmly  on  the  end  of  the  sacrum. 

As  the  head  passes  through  the  vaginal  orifice,  the  leg  on  the  side 
toward  the  practitioner  should  be  raised  and  flexed  at  the  knee,  to 
facilitate  its  passage,  and  to  enable  the  attendant  to  act  with  greater 
accuracy  and  promptness ;  the  fetal  head  should  be  received  into  the 
right  hand,  holding  it  loosely,  so  as  to  admit  of  the  motion  of  restitu- 
tion, and,  at  the  same  time,  a  finger  should  be  passed  around  the  neck 
of  the  child  to  ascertain  whether  the  umbilical  cord  is  coiled  around  it, 
and  which  commonly  occurs  when  the  cord  is  of  more  than  ordinary 
length. 

If  the  neck  be  embraced  by  one  or  more  turns  of  the  cord,  it  must 
be  liberated  by  loosening  it,  and  passing  it  over  the  head ;  or  else  the 
following  results  may  ensue,  especially  if  the  cord  be  short :  the  com- 
pression may  arrest  the  circulation  in  the  blood-vessels  of  the  neck, 
and  prevent  the  access  of  air  into  the  lungs  by  closure  of  the  trachea, 
thus  destroying  the  child ;  or,  the  expulsion  of  the  child  by  a  strong 
pain,  might  cause  inversion  of  the  womb,  or  serious  hemorrhage  by 
tearing  the  placenta  from  its  uterine  attachment.  If  the  cord  can  not 
be  easily  passed  over  the  head,  it  must  be  loosened  as  much  as  possible, 
so  as  to  prevent  strangulation  of  the  vessels  of  the  neck;  for  it  must 
be  remembered,  that  ordinarily,  even  with  two  or  three  coils  around 
the  neck,  the  cord  will  be  sufficiently  long  for  delivery  to  take  place, 
without  any  evil  consequences  to  the  mother.  Sometimes,  the  cord  is 
so  placed  around  the  neck,  that  it  has  to  be  divided  before  the  body 
can  be  born,  a  ligature  being  applied  as  soon  as  possible;  but  this  is 
done  only  in  those  extremely  rare  cases,  where  the  free  portion  of  the 
cord  is  rendered  so  short  as  to  endanger  inversion,  should  the  child  be 
delivered.  It  is  frequently  the  case,  that  an  evacuation  of  the  rectum 
occurs  with  the  expulsion  of  the  head,  but  the  compress  at  the  peri- 
neum serves  to  protect  the  hand  of  the  accoucheur  from  being  soiled 
by  it.  The  use  of  a  napkin  or  compress  in  supporting  the  perineum 
has  been  termed  most  absurd,  the  objection  being  that  it  absorbs  the 
great  secretion  of  mucus  designed  to  lubricate  the  parts  and  thereby 
render  the  passage  of  the  head  more  easy.  I  have  never  found  any 


;J04  KING'S  ECLECTIC  OBSTETRICS. 

difficulty  from  this  cause,  which  may  be  readily  obviated  by  applying- 
oil  or  lard  upon  the  perineum,  and,  if  necessary,  also  upon  the  com- 
press. The  principal  object  of  the  compress  has  just  been  referred 
to — the  support  can  be  given  as  well  without  as  with  it. 

As  soon  as  the  head  is  born,  the  child  commonly  commences  crying 
lustily ;  frequently,  however,  the  presence  of  mucus  interferes  with  its 
breathing,  and  the  practitioner  should  pass  a  finger  into  its  mouth  for 
the  purpose  of  removing  any  mucus  or  other  obstruction  that  may 
exist  there.  More  commonly,  simply  wiping  its  mouth  with  a  small 
napkin,  will  answer  the  purpose,  by  removing  any  mucus  that  may 
have  accumulated  around  the  lips. 

No  attempt,  whatever,  should  be  made  at  removing  the  body,  unless? 
much  delay  occurs  in  the  natural  process,  or,  the  life  of  the  child  is  in 
danger.  After  the  birth  of  the  head  a  short  interval  generally  fol- 
lows, but  if  this  is  prolonged,  serious  consequences  may  result;  under 
such  circumstances,  a  finger  may  be  inserted  into  the  axilla  nearest  the 
perineum,  and  traction  made  in  the  direction  of  the  axis  of  the  inferior 
strait,  while,  at  the  same  time,  pressure  is  to  be  made  by  the  other 
hand,  or  by  an  assistant,  on  the  abdomen  over  the  uterus.  One 
shoulder  disengaged,  the  other  follows,  and  the  child  is  born  without 
any  further  trouble.  I  prefer,  however,  as  the  rule,  to  arouse  the 
uterus  to  act  and  expel  the  child,  by  making  firm  pressure,  through 
the  abdominal  walls,  upon  the  uterine  fundus,  and  which  will  also  be 
found  to  facilitate  the  delivery  of  the  placenta.  But,  when  the  body 
follows  the  head  without  requiring  any  assistance  to  expel  it,  the 
right  hand  must  be  passed  along  with  the  head,  supporting  it  as  it 
moves,  and  the  body  must  be  supported  by  the  left  hand ;  and  as  soon 
as  the  child  is  expelled,  it  should  be  laid  upon  its  right  -side  with  its 
back  to  the  mother's  genitals,  to  prevent  it  from  receiving  any  of  the 
copious  discharge  which  follows,  into  its  mouth  ;  or  it  may  be  placed 
with  its  abdomen  toward  the  mother,  so  that  the  mouth  is  protected 
from  the  discharges.  And  in  moving  the  child,  care  must  be  taken 
not  to  make  sudden  or  powerful  traction  on  the  cord,  as  the  uterus  may 
become  thereby  inverted,  or  a  portion  of  the  placenta  by  being  roughly 
detached,  may  occasion  alarming  hemorrhage. 

The  expulsion  of  the  child  terminates  the  second  stage  of  labor; 
and  it  must  be  ever  borne  in  mind  by  the  physician,  that  in  a  case  of 
natural  delivery,  there  is  nothing  for  him  to  do  in  these  two  stages, 
except  to  witness  the  progress  of  the  labor,  to  console  and  encourage 
his  patient,  and  to  receive  the  child  after  its  expulsion.  Any  inter- 
ference, in  either  the  first  or  second  stages,  when  everything  i& 


MANAGEMENT  OF  NATURAL  LABOR.  305 

proceeding  favorably,  further  than  I  have  just  described,  is  exceed- 
ingly improper  and  criminal. 

I  am  aware  that  some  writers  advise,  and  many  practitioners  adopt 
the  plan  of  administering  Ergot  to  all  parturient  women,  in  the  second 
stage  of  labor,  for  ^  the  purpose  as  they  say,  of  promoting  the  easy 
expulsion  of  the  placenta,  and  a  subsequent  uterine  contraction,  thereby 
lessening  the  risk  of  hemorrhage;  but,  more  for  the  purpose,  as  I 
strongly  fear,  that  they  may  the  sooner  visit  another  patient  and 
procure  another  fee,  or,  perhaps,  from  want  of  sympathy  and  patience. 
I  consider  this  a  very  unscientific  and  censurable  practice,  and  have 
witnessed  many  accidents  resulting  from  it;  indeed,  when  the  influence 
of  the  Ergot  has  subsided,  the  reaction  that  must  ensue,  would  be  very 
apt  to  produce  a  condition  of  the.  uterine  tissue  favorable  to  hemorrhage 
from  that  organ.  From  a  practice  and  observation  of  thirty  years,  I 
am  thoroughly  convinced,  that  the  administration  of  Ergot  to  cause 
contractions  of  the  uterus,  whether  indicated  or  not,  occasions  and 
develops  a  greater  proportion  of  diseases  of  the  organ,  than  is  generally 
suspected  by  the  profession.  I  have  found  Sulphate  of  Quinia,  to 
answer  a  much  better  purpose,  when  it  is  desired  to  keep  up  permanent 
uterine  contraction  after  delivery,  though,  as  with  Ergot,  it  sometimes 
fails.  It  may  be  given  alone,  or  in  combination  with  powdered 
Cinnamon. 

A  natural  labor  may  be  accomrlished  in  two  hours,  or  it  may  con- 
tinue for  twenty-four  or  even  longer,  without  any  danger.  The  danger 
is  never  to  be  estimated  by  the  time  which  the  process  occupies,  nor  by 
the  severity  of  the  pains,  but  by  the  symptoms  which  are  present.  So 
long  as  the  parts  are  in  a  proper  condition,  position  and  presentation 
right,  and  the  pulse  unaffected,  there  is  no  necessity  for  haste,  alarm, 
or  officious  intermeddling,  no  matter  how  long  the  labor  continues ; 
the  practitioner  should  appear  cheerful,  resolute,  and  confident,  at  once 
check  any  complain cs  or  whisperings  among  the  female  attendants, 
and  use  all  means  to  sustain  the  patient's  spirits,  and  preserve  her  from 
a  despondency,  which  may  cause  a  suspension  of  uterine  contraction, 
and  convert  the  labor  into  a  difficult  one.  But,  if  the  parts  become 
hot  and  dry,  with  more  or  less  tenderness  on  being  touched,  and  the 
pulse  accelerated,  it  is  then  necessary  to  interfere,  calmly,  deliberately, 
without  violence  or  rudeness,  and  employ  the  proper  means  to  over- 
come the  difficulty. 

Sometimes,  after  the  delivery  of  the  child,  the  female  will  be 
attacked  with  violent  pains,  and  forcible  straining,  or  bearing-down 
efforts ;  as  these  may  be  owing  to  a  disposition  to  inversion  of  the 
20 


:',();;  KINO'S   KCLKCTIC  OHSTETUICS. 

uterus,  the  practitioner  should  endeavor  to  ascertain  their  cause,  and 
remove  it  if  possible,  at  the  same  time  urging  upon  the  female  the 
importance  of  resisting  these  efforts  as  much  as  possible,  lest  inversion 
should  be  produced  by  them. 

The  third  stage  of  labor  commences  after  the  birth  of  the  child  [the 
placenta  not  having  been  expelled  simultaneously  with  the  child],  and 
may  be  considered  the  most  important  period  of  the  process,  for  by  far 
the  greater  part  of  the  accidents  of  labor  occur  at  this  time,  either  from 
improper  intermeddling,  or  from  an  ignorance  of  the  correct  mode  of 
proceeding.  After  having  observed  that  the  child  is  living,  as  made 
known  by  its  crying,  it  must  be  separated  from  its  uterine  attachment; 
and  this  must  be  effected  without  any  exposure  of  the  mother — a  point 
which  I  desire  the  reader  especially  to  impress  upon  his  mind — as 
many  practitioners,  at  this  stage,  are  very  apt  to  needlessly  expose 
their  patients. 

As  soon  as  the  pulsation  of  the  cord  of  the  living  child  ceases 
toward  its  placental  extremity,  say  at  a  distance  of  five  or  six  inches 
beyond  its  abdomen,  or,  as  far  as  can  be  reached  by  the  hand  without 
introducing  it  into  vagina,  the  accoucheur  will  proceed  to  cut  the  cord. 
The  child  must  be  withdrawn  from  beneath  the  bedclothes,  if  the 
length  of  the  cord  will  permit;  or  if  too  short,  the  operation  must  be 
performed  under  the  bedclothes,  raising  them  to  effect  it,  taking 
especial  care,  however,  to  previously  place  over  the  parts  of  the  patient 
a  well-aired  cloth  or  towel,  that  they  be  perfectly  covered  and  con- 
cealed. 

The  ligatures,  which  had  been  prepared  in  the  early  part  of  the 
labor,  are  now  to  be  used ;  they  should  not  be  so  thin  as  to  risk  cutting 
through  the  membranes  and  vessels  of  the  cord,  nor  so  thick  as  to  be 
incapable  of  making  firm  compression,  sufficient  to  prevent  bleeding 
after  the  separation.  The  cord  is  to  be  tied  tightly  with  one  of  these, 
at  a  distance  of  an  inch  or  two  from  the  umbilicus,  care  being  had 
not  to  include  any  portion  of  protruding  intestine,  which  is  occasionally 
met  with;  as  in  these  cases,  the  incautious  ligaturing  of  the  intestinal 
protrusion  would  give  rise  to  the  most  disastrous  consequences.  This 
first'  ligature  is  of  importance,  for  if  it  be  not  tied  securely,  so  as  to 
compress  the  vessels,  the  child  may  lose  its  life  from  hemorrhage ; 
hence,  when  the  cord  is  large  or  fat  it  may  require  considerable  force 
to  ligate  it  properly ;  and  shortly  after  dividing  it,  it  will  be  well  to 
examine  and  ascertain  whether  any  hemorrhage  is  occurring  from  its 
free  extremity.  The  second  ligature  is  to  be  applied  two  or  three 
inches  beyond  the  first,  and  the  division  must  be  made  between  the 


MANAGEMENT  OF  NATURAL  LABOR.  307 

two  with  the  scissors,  being  careful  not  to  excise,  at  the  same  time,  a 
finger,  or  a  portion  of  the  child's  penis,  if  it  be  a  male.  In  this 
operation  the  practitioner  should  see  whafrhe  is  doing. 

I  am  well  aware  that  many  authors  advise  the  application  of  but  one 
ligature,  and  consider  the  employment  of  the  second  superfluous,  but 
I  prefer  two  in  all  cases,  not  from  an  erroneous  impression  held  by 
some,  that  the  female  may  lose  blood  through  the  unprotected,  open 
vessels  of  the  cord,  but  for  the  following  reasons :  In  the  first  place,  I 
am  well  convinced,  that,  in  many  instances,  by  thus  retaining  the 
blood  within  the  cord  and  placenta,  it  acts  as  a  provocative  to  uterine 
contraction  and  insures  a  speedy  detachment  and  expulsion  of  the 
placenta;  secondly,  it  is  much  more  cleanly,  and  dispenses  with  the 
pressure  of  the  thumb  and  finger  to  prevent  the  blood  from  spurting 
over  the  bedclothes,  or  even  on  the  clothing  of  the  practitioner;  thirdly, 
it  is  safe  in  case  of  twins,  with  anastomosed  circulation  in  the  placenta, 
should  the  practitioner,  as  is  frequently  the  case,  have  neglected  to 
place  his  hand  on  the  abdomen  to  ascertain  the  size  of  the  uterine 
tumor,  and  the  probability  of  the  presence  of  a  second  child ;  and 
fourthly,  should  it  be  judged  advisable  not  to  have  the  second  ligature, 
it  can  very  readily  be  removed,  or  another  division  of  the  extremity 
of  the  placental  portion  of  the  cord  be  made. 

It  is  sometimes  the  case  that  the  child  is  born  in  a  state  of  defective 
vitality,  asphyxia,  or  apoplexy.  If  the  pulsation  in  the  cord  continues, 
and  the  child  does  not  breathe,  some  cold  brandy  sprinkled  on  the 
region  of  the  diaphragm,  or  suddenly  dashing  cold  water  upon  its 
back  and  chest,  and  perhaps  a  few  light  frictions  made  rapidly  over 
the  body  and  extremities  with  a  piece  of  warm  flannel,  will  be  all  the 
means  required  for  its  resuscitation  ;  previous  to  which,  however,  the 
finger  must  be  passed  carefully  into  the  mouth,  as  far  down  as  possible, 
.in  order  to  remove  any  mucus  which  may  be  present,  obstructing  the 
respiration. 

Where  these  means  do  not  suffice,  it  may  become  necessary  to 
produce  artificial  respiration,  which  will  not,  however,  be  found  of  so 
great  value  in  cases  of  congenital  asphyxia  (in  which  air  has  never 
entered  the  fetal  lungs)  as  in  other  forms;  a  flexible  catheter,  or  laryn- 
geal  tube  must  be  cautiously  and  correctly  introduced  into  the  larynx, 
after  which  the  angles  of  the  mouth  must  be  closed  to  prevent  the 
escape  of  air ;  the  practitioner  will  then  apply  his  mouth  to  the  free 
end  of  the  tube  and  slowly  and  gently  inflate  the  lungs,  simulating 
breathing  by  making  gradual  pressure  on  the  chest  to  expel  the  air, 
which  he  continues  to  introduce  for  some  time ;  with  these  attempts 


Kix(;s  KCLKCTI 

he  may  also  sprinkle  water  or  brandy  over  the  face  and  chest,  apply 
warm  flannel  to  the  surface  and  administer  an  injection.  Some 
children  are  not  resuscitated  until  after  a  persevering  trial  of  an  hour 
or  two.  Respiration  may  also  be  excited  by  the  Sylvester  method, 
which  consists  in  lifting  the  child  by  its  two  arms  and  then  lowering 
it  to  a  sitting  posture,  gradually  carrying  the  arms  to  the  correspond- 
ing sides  of  the  body ;  these  elevating  and  depressing  movements  are 
to  be  continued  alternately  for  some  time;  they  tend  to  produce 
movements  strongly  resembling  those  of  natural  respiration.  Dr. 
Harvey  L.  Bird,  of  Baltimore,  advises  an  easy  and  speedy  method  in 
asphyxia,  which  consists  essentially  in  placing  the  palms  of  the  hands, 
(the  ulnar  edges  being  in  approximation)  under  the  back  of  the  child 
in  the  dorsal  decubitus,  the  thumbs  being  extended  toward  the  head 
and  extremities.  Keeping  the  ulnar  edges  of  the  hands  together,  the 
radial  sides  are  simultaneously  and  alternately  elevated  and  depressed 
so  as  to  raise  and  lower  the  child's  body  about  forty-five  degrees  above 
and  below  the  horizontal  line,  the  downward  movement  allowing  air  to 
enter  the  lungs,  while  the  upward  facilitates  its  escape.  These  alternate 
movements  performed  with  gentleness  and  regularity,  the  child's  head 
being  kept  in  the  median  line  of  the  body,  rarely  fail  in  effecting 
respiration  in  a  short  time,  where  life  is  not  extinct.  The  first 
symptom  of  returning  life  is  a  short  sob,  which  increases  in  frequency 
until  respiration  is  established,  after  which,  the  child  should  be  -kept 
at  a  sufficiently  elevated  temperature,  and  in  a  state  of  rest  and  quiet. 
Upon  the  first  return  of  vitality,  the  warm  bath  used  for  a  very  short 
time,  frequently  facilitates  the  restoration. 

This  condition  of  the  child  may  arise  from  a  premature  detachment 
of  the  placenta,  from  uterine  hemorrhage,  or  from  defective  nourish- 
ment, and  is  generally  accompanied  with  little  or  no  pulsation  in  the 
cord,  and  but  slight  action  of  the  heart,  and  as  nothing  is  to  be  gained 
by  maintaining  the  connection  of  the  fetus  with  the  uterus,  it  will  .be 
proper  to  ligate  and  cut  the  cord ;  but  in  all  instances  where  the  pulsa- 
tion of  the  cord  is  distinct,  though  feeble,  I  deem  it  inadvisable  to 
make  the  division,  until  respiration  has  been  fully  established  ;  and  in 
those  cases  where  the"  placenta  has  been  expelled,  it  should  be  Wrapped 
in  warm,  damp  cloths,  and  no  separation  be  made  until  all  pulsation  in 
the  cord  ceases. 

Apoplexy  may  be  known  by  the  lividity  of  the  face,  blueness  of  the 
surface,  labored,  or  obscure  action  of  the  heart,  and  feeble,  or  imper- 
ceptible pulsation  in  the  cord;  while,  in  the  instances  above  referred 
to,  the  color  of  the  surface  is  natural,  or  pale.  Apoplexy  may  result 


MANAGEMENT  OF  NATURAL  LABOR.  309 

from  prolonged  labor,  compression  of  the  head  by  a  narrow  pelvis,  or 
from  a  delay  in  the  expulsion  of  the  body  after  the  delivery  of  the 
head,  etc.,  and  it  must  be  treated  by  removing  the  cerebral  and  pul- 
monary engorgement.  In  these  cases  it  is  recommended  to  cut  the 
cord  without  ligaturing  it,  and  allow  the  escape  of  from  half  an  ounce 
to  an  ounce  of  blood,  at  the  same  time  sprinkling  tepid  water  over  the 
head,  face,  and  chest.  As  in  the  previous  instances,  the  mouth  and  fauces 
should  be  freed  from  mucus,  and  artificial  respiration  may  be  attempted. 
If  recovery  ensues,  the  surface  becomes  paler,  or  slightly  rosy,  the  pulse 
more  frequent  and  stronger,  and  efforts  at  inspiration  are  made ;  and 
when  these  symptoms  appear,  the  cord  may  be  tied.  In  all  these 
instances,  the  practitioner  should  not  become  discouraged  at  too  early 
a  period,  and  therefrom  slacken  his  efforts,  as  almost  hopeless  cases 
have  been  resuscitated  after  long,  but  patient  and  continued  treatment. 
When  the  pulsations  in  the  heart  and  cord  have  ceased  for  several  min- 
utes, attempts  at  restoration  will  be  useless. 

The  cord  having  been  cut,  the  child  is  to  be  passed  to  the  nurse,  who 
is  generally  ready  to  receive  it  in  a  small  blanket,  prepared  for  the 
purpose ;  but  as  its  body  is  very  slippery  with  the  waters,  blood,  or 
vernix  caseosa,  there  may  be  danger  of  dropping  it,  if  it  be  not  taken 
.hold  of  properly.  To  avoid  any  such  mortifying  accident,  the  prac- 
titioner will  seize  it  by  the  ankles,  with  his  left  hand,  placing  a  finger 
between  the  two  ;  and  will  have  the  back  of  its  neck  to  rest  in  the 
arch  formed  by  the  thumb  and  index  finger  of  his  right  hand,  resting 
the  upper  portion  of  its  back  upon  the  palm  of  his  hand,  and  placing 
the  points  of  the  three  remaining  fingers  under  its  right  axilla ;  thus 
held,  it  can  not  fall.  Some  advise  the  left  hand  to  be  placed  at  the 
breech,  with  one  finger  between  the  legs,  the  left  thigh  grasped  by 
the  thumb,  and  the  right  thigh  and  nates  resting  on  the  remaining 
fingers  and  palms  at  the  same  time  making  gentle  pressure  of  the  hands 
toward  each  other,  for  the  purpose  of  more  firmly  securing  the  child. 
Either  of  these  methods  may  be  safely  adopted. 

The  next  thing  is  to  ascertain,  if  it  has  not  been  previously  done, 
whether  there  is  another  child  in  the  uterus ;  this  may  be  known  by 
placing  the  hand  on  the  abdomen,  when  the  fundus  uteri  will  be  felt 
still  in  the  epigastric  region;  and  an  examination  per  vaginam  wrill 
detect  the  bag  of  membranes,  and  the  presenting  part.  If,  however, 
the  uterus  be  found  small  and  hard  like  a  solid  ball,  when  grasped 
through  the  abdomen;  or  small,  but  soft  and  doughy ;  or  small,  but 
becoming  hard  and  soft  alternately,  no  second  child  is  present,  and  the 
placenta  has  probably  passed,  either  partly  or  wholly  into  the  vagina. 


310  KINC'S   KCLKCTIC  or,sTi"r uics. 

If  it  be  hard  and  nearly  the  size  of  the  adult  head,  there  is  no  child, 
but  a  contraction  of  the  uterus,  upon  the  mass  inclosed  within  its  cav- 
ity; and  if  it  be  thus  large,  but  soft  and  doughy,  contraction  of  the 
organ  has  not  yet  taken  place  for  the  purpose  of  expelling  the  pla- 
centa. The  treatment  of  twin  cases  will  be  considered  hereafter. 
Having  ascertained  that  no  twin-child  is  present,  the  practitioner  will 
attend  to  the  delivery  of  the  placenta ;  occasionally,  the  same  pain  which 
expelled  the  child  likewise  ejects  the  placenta.  But,  usually,  from  five 
to  thirty  minutes  elapse  from  the  birth  of  the  infant,  before  the  uterine 
contractions  are  renewed  for  the  purpose  of  removing  the  secundines. 
The  left  hand  should  be  placed  on  the  hypogastrium,  and  if  the  uterus 
be  found  hard  and  well  defined,  and  the  patient  complains  of  some 
pain,  but  not  so  severe  as  before,  the  organ  is  contracting  and  expelling 
its  contents,  and  the  right  hand  should  be  ready  to  receive  them  as 
they  emerge.  If,  however,  the  uterus  be  found  large,  soft,  and  yield- 
ing, or,  if  it  be  not  felt  at  all,  it  may  be  caused  to  contract  by  gentle 
friction  and  pressure  on  it,  through  the  abdominal  parietes,  and  as  soon 
as  it  contracts,  the  woman  should  bear  down,  and  slight  traction  be 
made  upon  the  cord  with  the  right  hand  in  the  direction  of  the  axis 
of  the  superior  strait,  which  will  carry  the  cord  backward  to  the  os 
coccyx,  and  as  soon  as  the  placenta  moves  the  motion  will  be  recog- 
nized by  the  hand, — frequently,  a  crackling  sensation,  or  as  if  tearing 
a  piece  of  thin  silk.  In  the  meantime,  the  left  hand  should  continue 
upon  the  hypogastrium,  both  for  the  purpose  of  exciting  the  contrac- 
tions, as  well  as  to  admonish  a  cessation  of  the  traction,  whenever  the 
uterus  grows  soft,  or  manifests  a  tendency  at  some  portions  of  the 
fundus,  to  become  depressed  and  follow  the  direction  of  the  traction, 
and  thus,  probably,  be  partially  or  completely  inverted.  "Whether  the 
placenta  be  in  the  uterus  or  vagina,  if  the  soft  condition  of  the  uterua 
continues,  notwithstanding  the  means  used,  the  labor  may  be  compli- 
cated with  hemorrhage,  to  treat  which,  according  to  the  rules  hereafter 
given,  the  physician  must  be  thoroughly  prepared.  Crede's  method 
of  aiding  or  forcing  the  delivery  of  the  placenta  is  stated  to  be  supe- 
rior to  any  other,  as  it  does  not  endanger  the  tearing  away  of  the  cord, 
produces  a  tonic  contraction  of  the  uterus  that  diminishes  the  tendency 
to  subsequent  hemorrhage  or  to  severe  after-pains,  and  aids  in  the  pre- 
vention of  puerperal  disease.  It  simply  consists  in  grasping  the 
uterine  fundus,  through  the  abdominal  parietes,  with  the  hands,  in 
such  a  manner  that  the  organ  can  be  forcibly  compressed  from  above 
downward  and  backward ;  and  which,  as  the  rule,  causes  the  detach- 
ment and  ejection  of  the  placenta.  The  operation  is  the  more  readily 


MANAGEMENT   OF   NATURAL    LABOR..  311 

effected  the  sooner  it  is  employed  after  the  delivery  of  the  child.     Of 
course  this  method  is  inapplicable  when  hemorrhage  is  present. 

When  the  placenta  has  emerged  from  the  vulva,  it  should  be  twisted 
or  turned  around  several  times,  for  the  purpose  of  forming  a  cord  or 
string  of  the  membranes,  that,  thereby,  no  portion  of  them  be  left 
attached  to  the  uterine  surface,  thus  effecting  a  clean  and  perfect 
delivery,  and  the  accoucheur  should  always  examine  its  uterine  surface 
to  ascertain  whether  any  portion  of  it  has  remained  within  the  uterine 
cavity.  If  a  portion  of  the  membranes  be  left  within  the  uterine 
cavity,  it  may  give  rise  to  unpleasant  symptoms,  as  hemorrhage,  putre- 
faction, offensive  discharges,  etc.;  or  should  portions  of  them  pass- 
away  in  a  few  hours  afterward,  they  may  occasion  alarm  to  the  patient, 
or  lead  her  to  think  that  her  medical  attendant  is  not  perfect  in  this 
department  of  his  profession. 

It  is  always  proper  for  the  practitioner  to  ascertain  as  early  as  possi- 
ble after  the  birth  of  the  child,  whether  the  placenta  is  detached,  that 
he  may  remove  it,  and  this  may  usually  be  known  by  the  absence  of 
pulsation  in  the  cord,  which  becomes  cold  and  flabby,  and,  generally,, 
renewed  but  less  severe  pains  with  a  slight  discharge  of  blood;  but, 
unless  there  be  flooding,  or  some  other  circumstance  demanding  the 
immediate  delivery  of  it,  it  is  inadvisable  for  him  to  make  any  more 
active  efforts  than  above  named,  to  bring  about  its  expulsion  when  not 
effected  naturally,  for  at  least  one  hour  subsequent  to  the  child's 
egress  ;  then  he  will  treat  it  as  a  retained  placenta.  And  in  all  cases 
of  natural  labor,  it  must  be  thoroughly  impressed  upon  the  mind,  that 
no  force  or  haste  is  required  in  the  removal  of  the  placenta  and  mem- 
branes, but  they  should  be  drawn  forth  slowly  and  carefully,  to 
prevent  any  tearing  of  the  membranes,  or  cord,  or  other  unpleasant 
accidents  arising  from  too  hasty  a  removal  of  them  from  the  uterine 
or  vaginal  cavity. 

The  secundines  being  completely  removed,  the  practitioner  will 
request  the  nurse  to  bring  a  basin  or  some  other  vessel,  in  which  to 
place  them,  covering  them  with  a  cloth,  "for  the  sake  of  decency. " 
Then  he  will  ascertain,  by  placing  a  hand  on  the  abdomen,  whether 
the  uterus  is  small  and  contracted,  or  large  and  soft,  which  latter 
condition  indicates  a  tendency  to  internal  hemorrhage,  and  the  pulse 
and  countenance  of  the  patient  should  be  at  once  examined,  as  described 
hereafter.  The  delivery  of  the  placenta  closes  the  third  stage  of 
labor;  a  stage  of  the  process  which  requires  much  judgment  and 
presence  of  mind,  for  the  slightest  mistake  or  misconduct  might  lead 
to  the  most  serious  consequences  ;  and  with  ail  diiTiculties  which  may 


312  KI.\(;'S  KCI,I-:<  TIC  OHSTETIJICS. 

occur  at  this  stage,  as  well  as  their  treatment,  the  physician  should  be 
thoroughly  and  familiarly  conversant. 

As  soon  as  possible  after  the  birth  of  the  placenta,  and  especially  in 
cases  where  it  has  been  found  necessary  to  extract  it  artificially,  the 
practitioner  should  ascertain  that  there  is  no  inversion  of  the  uterus, 
and,  if  it  has  not  been  previously  accomplished,  should  likewise 
examine  the  placenta  and  membranes  to  see  that  the  whole  of  them 
have  passed  away,  and  that  no  portion  of  them  has  been  left  within 
the  uterine  cavity,  subjecting  the  patient  to  severe  pains,  nausea,, 
vomiting,  and  hemorrhage.  In  this  examination  both  surfaces  of  the 
placenta  should  be  inspected. 

Unless  there  are  certain  circumstances,  or  symptoms  present,  which 
will  be  referred  to  hereafter,  it  is  not  material  that  the  bandage  or 
binder  should  be  applied  until  after  the  expulsion  of  the  placenta.  It 
should  be  passed  under  the  patient's  back,  carefully,  being  made  to 
embrace  the  hips  and  the  whole  abdomen,  and  without  requiring  any 
efforts  on  her  part  to  assist  in  its  application;  it  should  be  pinned  or 
fastened  from  below  upward,  having  that  portion  around  the  hips  and 
lower  part  of  the  abdomen,  more  tightly  applied  than  the  rest,  or 
sufficiently  tight  to  occasion  a  very  slight  degree  of  uneasiness  when 
first  placed  on.  If,  however,  there  should  be  considerable  of  the 
discharges  present,  so  as  to  endanger  wetting  the  binder,  these  must 
first  be  removed,  or  covered  over  with  dry  cloths.  When  hemorrhage 
is  present,  the  bandage  is  in  the  way,  and  should  not  be  applied  until 
this  is  overcome.  Many  writers  consider  the  bandage  of  no  practical 
importance,  but  I  am  well  convinced  of  its  utility  during  the  first 
forty-eight  hours  after  labor  when  it  is  carefully  and  properly  applied. 
When  firmly  applied,  and  pressing  equally  upon  the  anterior  surface 
of  the  abdomen,  it  promotes  the  regular  contraction  of  the  uterus,  and 
gives  support  to  the  viscera  and  to  the  suddenly  relaxed  abdominal 
walls,  thereby  diminishing  the  risk  of  concealed  hemorrhage,  and 
syncope,  and  also  tends  to  prevent  air  from  passing  into  the  uterine 
cavity;  it  likewise  assists  a  return  to  the  natural  condition  of  the 
abdominal  parietes,  preventing  that  lax  state  of  the  integuments 
which  causes  a  "pendulous  belly,"  but  if  used  simply  for  this  purpose, 
it  can  well  be  dispensed  with.  When,  in  dropsy  of  the  abdomen,  the 
sudden  removal  of  the  pressure  is  effected  by  tapping,  unless  a  bandage 
is  applied  and  tightened  as  the  water  passes  off,  syncope  and  nausea 
are  very  apt  to  ensue;  and  fatal  syncope  has  occured  shortly  after 
parturition,  from  no  other  attributable  cause  than  the  omission  of  the 


MANAGEMENT  OF  NATURAL  LABOR.  313 

bandage;  the  removal  of  the  uterine  contents  in  labor,  whereby  a 
removal  of  pressure  is  speedily  accomplished,  is  a  somewhat  analogous 
case,  requiring  similar  measures  for  relief.  The  binder  may,  if  neces- 
sary, be  worn  for  a%few  days  succeeding  delivery,  not  certainly  to 
exceed  three  or  four ;  and  its  longer  employment,  as  advised  by  some 
physicians,  for  two  or  three  weeks,  strikes  me  as  being  a  useless 
measure.  A  bandage  applied  too  tightly,  and  especially  when  worn 
longer  than  the  first  few  days,  would,  in  my  estimation,  very  much 
endanger  some  displacement  of  the  uterus,  paralyze  or  greatly  weaken 
the  abdominal  muscles,  force  the  uterus  into  the  pelvic  cavity  by 
pressing  the  intestines  upon  it,  check  to  a  greater  or  lesser  extent  a 
free  circulation  in  the  organ  by  compression  of  the  vena  cava  and 
pelvic  veins,  and  greatly  interfere  with  the  accomplishment  of  involu- 
tion. It  should  be  applied  so  that  the  uterus  will  be  pressed  down- 
ward rather  than  backward ;  and,  in  some  cases,  it  may  be  advisable 
to  place  a  sufficiently  thick  compress  under  it,  in  order  to  secure  the 
proper  compression  to  aid  in  preventing  uterine  relaxation  with  flood- 
ing. It  will  be  observed  from  the  above,  that  since  the  publication 
of  the  last  edition  of  this  work,  further  and  more  attentive  experience 
has  considerably  modified  the  views  therein  expressed  relative  to  the 
binder.  Generally,  the  binder  is  applied  by  the  nurse  or  some  female 
friend,  but  the  physician  should  understand  how  to  apply  it  himself, 
and  should  always  ascertain  that  it  is  properly  placed  and  tightened 
before  leaving  the  patient.  He  will,  frequently^  be  requested  to  place 
the  bandage  on  his  patient,  but,  as  a  general  rule,  I  consider  it  a 
task  entirely  out  of  his  province,  and  one  which  should  be  invariably 
performed  by  a  female.  To  be  of  the  greatest  service,  the  bandage 
should  be  applied  next  the  skin,  and  I  can  not  conceive  of  any  office 
more  offensive  to  female  purity  and  modesty,  and  more  repugnant  to 
the  sensitiveness  of  a  man  of  honor  and  refinement,  than  that  of 
bandaging  a  naked  and  exposed  parturient  woman.  True,  physicians 
and  females  have  often  to  be  placed*  in  even  more  delicate  and  exposed 
situations  than  this,  but  then  it  is  only  in  those  cases  in  which  health 
and  life  render  it  imperatively  necessary,  and  in  which,  from  the 
dangers  to  the  patient,  modesty  becomes  a  vice.  She  must  be,  truly, 
an  ignorant  nurse,  who  is  incapable  of  correctly  bandaging  a  parturient 
female.  Although  I  consider  the  application  of  the  bandage,  the  duty 
of  the  nurse,  yet  it  is  the  physician's  duty  to  ascertain,  after  it  has  been 
done  and  the  female  covered,  whether  it  is  applied  properly.  And  in 
those  instances  where  he  is  desired  to  place  the  bandage,  himself,  and 
no  excuses  will  be  received,  he  may  adjust  it  over  the  body-garment 


KINC'S   K(  LKCTIC 

of  the  patient,  and  thus  obviate  the  necessity  for  exposure.  After  the 
application  of  the  binder,  some1  warm,  dry.  cloths  .should  be  loosely 
applied  to  the  vulva,  for  the  purpose  of  absorbing  the  discharges,  and 
preventing  them  from  soiling  the  dry  clothes  of  the  patient.  These 
cloths  should  be  examined  from  time  to  time,  while  in  the  house,  for 
the  purpose  of  aiding  in  the  determination  of  the  degree  of  hemor- 
rhage; and  for  the  same  purpose,  the  hand  may  be  placed  upon  the 
abdomen  occasionally,  to  learn  if  the  uterus  continues  contracted ;  the 
pulse  likewise  ought  to  be  felt  several  times,  and  inquiries  be  made 
as  to  whether  the  patient  experiences  any  sensations  of  faintness. 

The  "  putting  to  bed,"  as  it  is  termed,  in  which  the  patient  is  moved 
into  her  regular  bed,  should  take  place  as  soon  as  circumstances  will 
permit  ;  in  ordinary  labors  it  may  be  accomplished  in  an  hour  after 
the  delivery,  or,  following  the  washing  and  dressing  of  the  child ;  but 
if  the  labor  has  been  tedious,  or  very  painful,  it  must  be  delayed 
according  to  the  strength  and  circumstances  of  the  patient.  In  the 
process  of  "putting  to  bed"  the  practitioner  must  be  very  careful  that 
the  patient  uses  no  exertions  on  her  part  for  the  purpose  of  giving 
assistance/  and  that  she  be  not  removed  from  the  horizontal  position, 
lest  hemorrhage  be  thereby  induced.  The  husband  and  two  females 
may  carefully  raise  and  remove  her,  or  she  may  be  carried  in  a  strong 
sheet,  held  by  four  persons,--  it  matters  not  how  the  removal,  or 
"putting  to  bed,"  is  executed,  so  it  is  with  care,  and  an  attention  to 
the  above  points.  But,  under  any  circumstances,  the  patient  should 
not  be  allowed  to  lie  for  any  length  of  time  with  the  discharges  and 
damp  cloths  around  her,  these  must  be  removed  as  promptly  as  the 
condition  of  the  patient  will  admit,  and  in  a  manner  not  calculated  to 
unnecessarily  expose  her  to  any  dangers. 

As  soon  as  the  mother  can  be  safely  left  for  a  short  time,  and  the 
nurse's  attention  to  her  can  be  dispensed  with,  the  child,  which  had 
been  warmly  wrapped  up  and  placed  in  some  safe  location,  must  be 
attended  to.  It  must  be  washed  and  dressed.  This  is  almost  always 
the  task  of  the  nurse,  or  some  female  present ;  yet  the  practitioner 
should  understand  how  it  is  to  be  done,  in  case  inquiry  be  made  of 
him,  or  he  should  be  left  in  a  condition  where  he  would  be  required 
to  act  the  part  of  nurse ;  a  part,  however,  to  which  I  most  decidedly 
object,  except  in  imperative  cases. 

The  body  and  limbs  should  be  lubricated  with  Sweet  Oil,  fresh 
Lard,  or  fresh  Butter,  which  will  assist  in  the  more  ready  removal 
of  the  sebaceous  matter  with  which  the  skin  of  the  child  is  covered 
at  birth;  after  which,  warm  Soap-suds  will  be  the  only  application 


MANAGEMENT    OF    NATURAL    LABOR.  315 

required.  If  the  above  substance  is  not  thoroughly  cleansed  from  the 
skin,  it  may  occasion  painful  and  troublesome  cutaneous  excoriations. 
Be  careful  that,  in  washing  and  drying,  the  tenderness  and  integrity  of 
the  infant's  skin  be  regarded,  as  too  much  pressure,  or  too  much  fric- 
tion may  bruise  or  abrade  it;  soft  cotton,  or  linen  should  be  used,  both 
in  the  washing  and  drying.  Some  apply  cold  water  to  the  infant, 
but  this  is  wrong,  and  frequently  injurious,  requiring  a  very  robust 
child  to  pass  through  the  ordeal  with  safety.  The  child  has  just 
emerged  from  a  situation  of  an  elevated  temperature,  and  a  reduction 
of  this  temperature  too  suddenly,  or  too  soon  after  birth,  would, 
especially  in  those  who  are  weak  and  delicate,  be  very  apt  to  occasion 
serious  and  even  fatal  consequences.  In  washing  the  child's  head, 
many  nurses  are  accustomed  to  apply  a  small  portion  of  warm  spirits 
of  some  kind,  for  the  purpose,  as  they  say,  of  preventing  its  taking  cold ; 
whether  this  accomplishes  the  intention  or  not,  there  can  be  no  objec- 
tion to  the  practice,  if  too  great  a  quantity  of  liquor  be  not  employed. 
After  the  washing,  the  accoucheur  will  be  called  upon  to  dress  the 
cord;  but  previous  to  this,  it  will  be  proper  for  him  to  examine  the 
child,  and  ascertain  that  it  is  not  malformed  or  blemished  with  nsevi, 
and  that  its  limbs,  hands,  feet,  mouth,  genital  organs,  etc.,  are  perfect. 
Some  examine  for  this  purpose,  even  before  its  washing.  This  having 
been  done,  a  piece  of  soft  linen  must  be  doubled,  so  as  to  form  a  square 
whose  sides  measure  six  or  seven  inches ;  this  is  again  doubled  and 
folded  in  a  triangular  form,  somewhat  in  the  manner  of  preparing  a 
paper  filter,  so  that  its  point,  which  will  be  the  center  of  the  square 
when  opened,  may  be  applied  to  the  flame  of  a  lamp  or  candle,  to  form 
an  opening  of  sufficient  size,  through  which  to  pass  the- cord.  I  prefer 
making  the  orifice  by  burning  instead  of  cutting,  as  its  edges  are 
thereby  much  softer  and  less  liable  to  increase  any  existing  irritation 
of  the  parts  in  contact  with  it.  This  is  then  opened,  and  through  the 
orifice  thus  formed  in  the  piece  of  linen,  doubled,  the  cord  is  to  be 
passed.  The  linen  may  now  be  allowed  to  lie  upon  the  abdomen,  and 
another  piece  placed  over  it  and  the  cord,  or  the  cord  may  be  wrapped 
up  in  the  first  piece.  But  whichever  plan  is  adopted,  the  cord  must 
be  placed  upward  along  the  abdomen,  rather  to  the  left,  in  order  to 
avoid  any  compression  of  the  liver,  and  then  be  secured  in  this  position 
by  a  bellyband  or  bandage,  passed,  but  not  too  tightly,  around  the 
child's  body.  If  any  blood  be  found  to  ooze  from  the  end  of  the  cord 
previous  to  dressing  it,  another  ligature  must  be  applied  nearer  the 
umbilicus.  The  remaining  piece  of  the  funis  umbilicalis  dr,ies  up, 
and  usually  falls  off  in  five  or  six  days,  though  this  may  vary  from 


316  KING'S  ECLECTIC  OHSTKTIMCS. 

two  to  sixteen  days.  It  is  not,  commonly,  necessary  for  the  practi- 
tioner to  examine  the  cord  at  subsequent  visits,  for  every  time  the 
nurse  bathes  the  child,  she  makes  it  a  matter  of  duty  to  inspect  its 
condition  herself,  and  from  her  any  information  relative  to  it,  under 
ordinary  circumstances,  can  be  obtained.  As  the  cord  shrivels  and 
diminishes  in  thickness,  it  soon  has  the  appearance  of  a  fine  spider- 
web,  and  which  may  lead  the  accoucheur  to  hasten  its  separation 
by  cutting  it  with  a  knife  or  scissors,  but  he  must  be  careful  not  to 
attempt  this;  I' have  known  such  an  operation  to  be  followed  by 
severe  ulceration,  and  also  by  hemorrhage.  After  the  application 
of  the  bandage,  the  child  should  be  lightly  and  loosely  dressed, 
according  to  the  season,  and  all  cumbersome  and  tight  clothes  placed 
aside,  as  injurious  to  its  health  and  welfare. 

The  child  should  be  placed  to  the  breast  as  soon  as  possible,  for,  in 
many  instances,  it  will  at  once  obtain  a  supply  of  the  mother's  milk ; 
or  if  there  be  no  milk  present,  the  attempt  at  sucking  is  very  apt  to 
be  followed  by  its  early  secretion ;  but  should  it  fail  to  suck,  or  should 
no  milk  have  been  secreted,  there  will  be  no  necessity  for  feeding  it 
until  several  hours  have  elapsed.  Some  recommend  it  to  be  kept  from 
the  breast  for  ten  or  twelve  hours ;  this  may  answer  in  cases  where 
there  is  much  exhaustion,  or  where  the  labor  has  been  protracted ;  but 
in  ordinary  instances  I  prefer  placing  it  to  the  breast  as  early  as  possi- 
ble; and  this,  not  so  much  for  the  purpose  of  food,  as  to  excite  uterine 
contraction  and  thereby  prevent  hemorrhage.  I  have  met  with  many 
instances  in  which,  for  several  hours  after  the  birth  of  the  child,  any 
attempt  made  by  it  to  suck,  was  instantly  followed  by  more  or  less 
severe  after  pains.  Should  it  become  advisable  to  feed  the  child,  a 
little  warm  milk  and  water,  without  sweetening,  or  some  thin  gruel, 
will  be  the  only  food  required — [if,  however,  these  articles  must  be 
sweetened,  it  will  be  better  to  use  sugar  of  milk,  and  not  cane  sugar] ; — 
but  after  it  obtains  the  mother's  milk,  no  other  food,  whatever,  should 
be  allowed,  unless,  for  some  urgent  reason. 

The  substance  collected  in  the  intestines  of  the  fetus  during  utero- 
gestation,  is  called  "  meconium,"  and  if  it  be  not  removed  soon  after 
birth,  it  will  occasion  gripings,  colic,  etc.  The  first  breast-milk  of  the 
mother,  secreted  after  delivery,  is  the  best  agent  for  the  removal  of 
the  meconium ;  it  is  called  colostrum,  and  contains,  in  addition  to  the 
common  milk  globules,  numerous  large  cells,  or  granular  corpuscles, 
whose  investing  membrane  is  filled  with  oil,  or  common  milk  globules, 
similar  to  those  which  are  floating  free  in  the  surrounding  fluid.  This 
colostrum  appears  to  exert  a  laxative  influence  on  the  child,  and  is 


MANAGEMENT  OF  NATURAL  LABOR.  317 

superior  to  any  other  agent  for  the  above  purpose ;  if  it  can  not  be 
had  within  a  few  hours  succeeding  delivery,  some  Sweet  Oil,  or  Castor 
Oil  may  be  given,  to  effect  the  evacuation.  I  do  not  believe  in  dosing 
an  infant  with  medicine  as  soon  as  it  is  born,  for,  owing  to  the  cus- 
toms and  habits  of  society  it  will  become  a  charge  to  the  physician 
soon  enough,  without  attempting  medication  from  the  moment  of  birth  ; 
therefore,  care  and  prudence  should  be  manifested  in  making  use  of 
laxatives  to  purge  off  the  meconium.  And,  above  all  things,  for  the 
sake  of  decency  and  of  science,  forbid  that  nauseous,  abominable,  and 
worse  than  heathenish  practice,  which  some  old. nurses  have,  of  forcing 
down  the  child's  throat,  a  disgusting  mixture  of  urine  and  molasses. 

During  these  attentions  to  the  child,  the  mother  must  by  no  means 
be  neglected;  her  pulse  should  be  examined  from  time  to  time,  and 
other  investigations  pursued  to  ascertain  the  condition  of  the  uterus, 
and  whether  any  disposition  to  hemorrhage  exists.  The  practitioner 
should  NEVER  leave  the  house  for  at  least  one  hour  after  the  delivery 
of  the  placenta,  and  he  who  leaves  earlier  than  this,  is  criminally 
guilty  of  the  loss  of  his  patient,  should  she,  shortly  after  his  leaving, 
die,  from  uterine  hemorrhage.  There  is  no  excuse  for  him.  If  it  is 
absolutely  necessary  for  him  to  leave  the  house,  previous  to  the  ter- 
mination of  the  hour,  let  him  have  another  physician  called  in,  to 
temporarily  supply  his  place.  If  the  labor  has  been  a  tedious  one, 
or  the  patient  is  much  exhausted,  or  if  the  womb  does  not  contract 
properly,  the  house  should  not  be  left  for  even  a  longer  period  than 
an  hour,  depending,  however,  upon  the  circumstances  of  the  case. 

When  about  to  return  home,  the  accoucheur  should  place  his  hand 
upon  the  patient's  abdomen,  to  learn  whether  the  uterus  is  small,  hard, 
and  contracted;  he  should  examine  the  condition  of  the  pulse,  and 
likewise  request  the  nurse  to  show  him  the  cloth  which  had  been 
placed  at  the  vulva,  that  he  may  form  some  idea  of  the  quantity  of 
blood  discharged.  He  should  direct  a  light,  non-stimulating,  but 
nutritious  diet,  as,  of  toast  and  tea,  gruel,  barley-water,  and  similar 
articles,  favoring  the  patient's  desires  in  this  respect  when  they  are  not 
decidedly  objectionable,  and  positively  prohibit  the  admission  of  friends 
into  the  parturient  room,  for  a  period  of  at  least  twenty-four  hours ; 
the  room  must  be  kept  comfortably  warm,  and  properly  ventilated 
without  exposure  of  the  patient,  and  perfectly  free  from  any  noise  or 
excitement.  Nervous  irritation,  fretfulness,  feverishness,  mania,  and 
even  death,  have  followed  the  use  of  a  diet  not  sufficient  to  afford  the 
nourishment  and  strength  required  during  the  puerperal  period.  He 
should  leave  the  most  positive  orders  that  the  female  shall  not  assist 


318  KING'S    K(  I.I  (Tic   OBSTETRICS. 

herself  in  anything,  and  especially  that  she  continue  in  the  horizontal 
position,  for  the  first  twenty-four  hours  after  labor,  for  even  the 
momentary  semi-erect  posture  has  frequently  occasioned  alarming 
hemorrhage;  and  he  should  also  ascertain  that  the  bandage  is  properly 
secured. 


CHAPTER   XXVI. 

'ATTENTIONS    REQUIRED    SUBSEQUENT    TO    DELIVERY,    DURING    THE 
PUERPERAL    PERIOD. 

IN  about  twelve  hours  the  patient  should  be  again  visited  by  her 
medical  attendant,  and  even  sooner  than  this,  where  the  labor  has 
been  tedious,  or  where  there  is  a  disposition  to  hemorrhage.  As  with 
the  process  of  natural  labor,  so  with  the  puerperal  state,  when  unin- 
terrupted by  accidents,  no  interference  is  required  on  the  part  of  the 
practitioner;  the  patient  will  gradually  attain  her  normal  condition, 
unaided;  yet  as  many  females,  who  pass  through  their  labors  with 
safety,  perish  in  the  subsequent  puerperal  condition  from  inflammatory 
attacks,  it  is  the  duty  of  the  attendant  to  superintend  this  condition, 
that  he  may  at  once  adopt  the  proper  measures  to  remove  any  abnor- 
mal symptoms  that  may  arise. 

The  shock  to  the  nervous  system  from  labor,  effects  a  derangement 
varying  from  mere  restlessness  to  absolute  hysteria;  in  easy  labors, 
the  patient  soon  recovers  from  it,  requiring  only  a  state  of  rest  and 
sleep.  When  severe,  it  is  characterized  by  symptoms  of  exhaustion, 
with  an  alteration  in  the  appearance  of  the  eye,  an  anxious  counte- 
nance, derangement  of  the  brain,  the  sensibility  of  which  is  either 
diminished  or  increased,  and  a  disturbance  of  the  circulating  and 
respiratory  systems,  as  manifested  by  the  pulse,  which  is  slow  and 
labored,  or  rapid  and  fluttering,  or  alternating  from  slow  to  rapid,  and 
which  must  not  be  mistaken  for  the  pulse  of  peritonitis,  and  also  by 
the  hurried,  panting  breathing. 

The  pulse  will  be  found  to  increase  during  the  second  stage  of  labor, 
to  diminish  after  this  is  completed,  and  to  rise  again  on  the  secretion 
of  the  milk.  A  pulse  ranging  from  100  to  110  in  the  puerperal  state, 
should  be  watched,  though  it  is  not  always  indicative  of  danger.  A 
quick  pulse  may  be  present  when  a  large  clot  is  in  the  uterus,  it  may 
occur  with  diarrhea,  gastric  disturbance,  or  severe  after-pains ;  and 
when  found  immediately  after  delivery,  it  frequently  indicates  hemor- 


ATTENTIONS   SUBSEQUENT    TO    DELIVERY.  319 

rhage.  A  quick,  feeble,  fluttering  pulse  occurs  in  the  collapse  from 
the  nervous  shock.  There  is  a  sensation  of  fatigue  experienced  in  the 
shoulders  and  in  the  muscles  of  the  abdomen,  which  sometimes  persists 
for  three  or  four  days.  It  is  occasioned  by  the  muscular  efforts  made 
during  the  second  stage  of  labor,  and  which  may  be  discriminated  from 
peritonitis,  by  the  pulse  not  being  increased,  by  no  aggravation  of  the 
pain  on  pressure,  and  by  the  absence  of  febrile  symptoms.  When 
these  symptoms  are  not  very  severe,  they  will  subside  upon  keeping 
the  patient  quiet,  and  free  from  excitement,  together  with  a  few  hours 
sleep.  If  severe,  small  doses  of  the  compound  powder  of  Ipecacuanha 
and  Opium  may  be  administered  with  advantage.  In  some  instances, 
the  indication  for  Sp.  Tr.  Xanthoxylum,  Pulsatilla  or  the  Parturient 
Balm  will  be  present.  The  support  derived  from  the  bandage  will, 
usually,  quickly  overcome  any  weakness  that  may  exist  in  the  abdom- 
inal walls.  Not  unfrequently  small  doses  of  Sulphate  of  Quinia,  Sp. 
Tr.  of  Macrotys,  of  Aconite,  of  Golsernium,  or  even  of  Nux  Vomica, 
according  to  the  indications,  will  prove  efficacious.  The  diet  should 
be  nutritious,  the  patient  kept  quiet,  the  visits  of  friends  prohibited, 
and  for  a  few  days  nursing  may  be  avoided.  When  symptoms  of  col- 
lapse or  great  exhaustion  are  present,  stimulants  may  be  allowed,  as 
a  moderate  quantity  of  brandy  and  water,  wine,  or  Aqua  Ammonia,  and 
these  may  be  given  in  conjunction  with  the  compound  powder  of  Ipe- 
cacuanha and  Opium.  Special  attention  has  recently  been  called  to 
Erythroxylon  Coca,  either  in  tincture,  fluid  extract,  or  infusion,  which 
will,  in  many  instances,  no  doubt,  be  found  decidedly  beneficial.  In 
anemic  conditions,  small  doses  of  the  Acid  Solution  of  Iron  may  be 
associated  with  the  other  remedial  measures.  The  stimulants  may  be 
omitted  as  reaction  comes  on,  for  if  continued  beyond  this,  they  will 
be  likely  to  produce  mischief. 

The  vagina,  notwithstanding  its  great  distension,  soon  recovers  its 
normal  size,  and  the  heat  and  soreness  speedily  disappear,  unless  the 
labor  has  been  protracted  during  the  second  stage;  or  the  lochial  dis- 
charge becomes  acrid.  The  integuments  of  the  abdomen  do  not  so  readily 
recover  their  natural  condition;  they  remain  loose  and  flaccid  for  a 
long  time ;  but  if  the  bandage  be  properly  applied,  the  only  evidence 
of  pregnancy  which  they  afford,  will  be  the  white  streaks  on  the  exter- 
nal surface  of  the  abdomen,  linece  albicantes.  The  contractions  of  the 
uterus  after  delivery,  not  only  reduce  its  size,  but  prevent  uterine 
hemorrhage,  remove  all  substances  from  within  its  cavity,  and  diinm- 


320  KING'S  ECLECTIC  OBSTETIUCS. 

ish  the  caliber  of  its  vessels  and  sinuses.  The  contraction,  however 
is  not  permanent,  but  is  followed,  after  a  short  time,  by  an  interval  of 
relaxation;  and  these  alternate  contractions  and  relaxations  continue 
for  eight  or  ten  days,  during  which  time  the  organ  can  be  felt  and 
examined  through  the  relaxed  Avails  of  the  abdomen,  after  which  it 
becomes  so  reduced  in  size  as  to  descend  in  the  pelvis,  when  it  can  no 
longer  be  distinguished  through  the  abdomen.  A  day  or  two  after 
delivery,  the  lining  membrane  of  the  internal  cavity  of  the  uterus, 
appears  loose,  somewhat  softened,  wrinkled,  and  covered,  more  or  less, 
with  patches  of  decidua.  At  the  placeutal  site  the  part  is  raised,  and 
the  surface  is  unequal,  like  a  granulating  ulcer,  and  its  size  is  very 
much  reduced.  The  whole  internal  surface  of  the  organ  is  of  a  dark 
ash  color,  with  a  greenish  or  brownish  discharge  upon  it,  which  has 
been  mistaken  for  a  gangrenous  condition.  The  uterine  structure  is 
not  so  dense  as  in  its  natural  state ;  its  fibers  are  more  distinct,  and 
the  sinuses  are  still  evident,  being,  filled  with  clots  of  blood  at  the  pla- 
cental  site.  The  os  and  cervix  uteri  appear  bruised  and  ecchymosed, 
and  small  lacerations  or  abrasions  may  sometimes  be  observed,  which 
occasionally  degenerate  into  ulcers.  The  orifice  remains  open  for 
several  days,  closing  gradually. 

The  contractions  of  the  uterus,  which  ensue  after  delivery,  are  usually 
accompanied  with  more  or  less  pain,  termed  AFTER-PAINS,  and 
which  are  more  common  to  multiparous  women  than  primiparous; 
being  more  generally  absent  in  the  latter.  Females  who  are  the  sub- 
jects of  dysmenorrhea  are  said  to  be  the  most  liable  to  these  pains, 
which  vary  greatly  in  their  severity  and  duration.  They  commence 
soon  after  delivery,  say  from  half  an  hour  to  an  hour,  and  continue 
from  twenty-four  to  sixty  hours.  No  bearing-down  efforts  accompany 
them,  nor  is  the  frequency  of  the  pulse  increased.  These  pains  are 
useful  not  only  in  reducing  the  uterus  to  its  non-gravid  condition,  but, 
by  expelling  coagula,  pieces  of  membrane,  .and  the  fibrinous  clots 
which  plug  up  the  sinuses,  they  also  prevent  irritative  fever.  They 
are  frequently  brought  on,  or  increased,  upon  applying  the  child  to  the 
breast,  which  is  an  argument  in  favor  of  this  being  done  at  an  early 
period  after  delivery,  in  order  to  assist  in  promoting  these  contractions 
and  thereby  lessening  the  risk  of  hemorrhage. 

After-pains  may  be  usually  distinguished  from  peritonitis,  by  their 
periodical  returns,  by  being  unaccompanied  with  fever  or  an  excited 
pulse,  by  the  persistence  of  the  secretion  of  milk,  and  the  discharge  of 


ATTENTIONS    SUBSEQUENT    TO    DELIVERY.  321 

the  lochia,  and  by  not  increasing  in  severity  upon  pressure,  though  it 
must  be  recollected  that  the  muscles  of  the  abdomen  may  feel  sore 
when  pressed  upon.  They  require  no  treatment  unless  severe,  wheii 
they  may  be  overcome  by  the  administration  of  Sp.  Tr.  Macrotys,  or 
compound  powder  of  Ipecacuanha  and  Opium,  either  singly  or  in 
alteration;  the  mixture  known  as  Diaphoretic  Powder  has  been  admin- 
istered with  benefit.  Should  the  pains  resist  the  use  of  these  agents, 
and  which  resistance  will  usually  be  found  to  depend  upon  retention 
of  coagula,  the  rectum  should  be  unloaded  by  a  purgative  enema,  and 
hot  fomentations  should  be  applied  to  the  abdomen,  which  will  cause 
a  prompt  discharge  of  the  clots,  followed  by  immediate  relief  to  the 
patient.  The  application  of  Hops,  heated  in  a  small  sack  or  equal  parts 
of  Hops  and  Tansy,  made  into  a  fomentation  with  Whisky  or  some 
kind  of  Spirits,  and  applied  over  the  abdomen  warm,  renewing  it  from 
time  to  time,  together  with  the  internal  administration  of  compound 
powder  of  Ipecacuanha  and  Opium  five  grains,  repeating  the  dose 
every  three  hours,  has,  in  my  practice,  afforded  prompt  relief  in  severe 
after-pains  that  had  obstinately  resisted  all  previous  treatment.  Sul- 
phate of  Quinine,  in  doses  of  two  to  five  grains,  one,  two,  or  three 
times  a  day,  alternating  with  Sulphate  of  Morphia,  in  doses  of  one- 
eighth  to  one-fourth  of  a  grain,  will  frequently  check  after-pains  which 
have  resisted  other  means.  The  process  of  involution  is  greatly  facil- 
itated in  a  majority  of  instances  by  the  use  of  Macrotys  and  Pulsatilla; 
Phytolacca  also  seems  to  exert  a  specific  influence  in  this  regard,  as 
well  as  the  Parturient  Balm.  Other  remedies  have  been  recommended 
in  this  difficulty,  but  I  have  found  the  above  all-sufficient  in  the  nu- 
merous cases  which  have  come  under  my  notice.  There  is  a  species 
of  pain,  of  a  very  excruciating  character,  which  sometimes  follows 
delivery ;  it  does  not  intermit  like  the  ordinary  after-pains,  but  is  con- 
tinuous, and  is  located  in  the  coccyx  and  extremity  of  the  sacrum.  It 
may  be  relieved  by  introducing  an  opiate  suppository  into  the  rectum, 
or  by  thejnternal  administration  of  the  compound  powder  of  Ipecac- 
uanha and  Opium,  or  other  mild  anodyne. 

Rheumatism  of  the  uterus  may  render  the  retraction  of  this  organ 
after  delivery,  very  imperfect,  causing  it  to  continue  enlarged  above 
the  superior  strait.  In  this  case  the  after-pains  are  prolonged  and 
very  severe,'  and  the  want  of  sufficient  contraction  upon  the  bleeding 
vessels  may  give  rise  to  profuse  hemorrhage.  This  may  be  overcome 
by  pursuing  a  treatment  similar  to  that  named  in  another  chapter. 

21 


322  KINO'S  ECLECTIC  OBSTETRICS. 

In  addition  to  the  above-named  conditions,  there  are  several  others, 
which  it  is  important  to  inquire  into  upon  the  first  visit  after  delivery; 
among  these  may  be  named  the  state  of  the  excretions.  During  the 
second  stage  of  labor,  perspiration  becomes  quite  copious,  diminishing 
after  the  delivery,  but  not  immediately  returning  to  the  ordinary 
standard;  sometimes  it  has  a  greasy  feel,  and  a  sickly  odor,  and  the 
skin  is  soft  and  flabby,  gradually  returning  to  its  natural  state. 

Particular  inquiry  should  be  made  as  to  the  urinary  discharge,  and 
on  this  point  the  practitioner  should  fully  satisfy  himself.  It  is 
frequently  the  case,  that  the  patient  is  unable  to  void  the  urine,  or 
it  passes  with  difficulty,  and  in  small  quantity.  This  may  distend  the 
bladder,  giving  rise  to  pains,  fever,  violent  spasms,  and,  perhaps, 
rupture  of  the  bladder.  Pressure  of  the  head  upon  the  bladder  and 
urethra,  during  its  passage  through  the  pelvis,  usually  occasions  this 
difficulty.  Whenever  there  exists  any  want  of  free  urination,  the 
bladder  should  be  at  once  emptied  by  means  of  a  catheter,  which  may 
have  to  be  used  several  times  before  the  parts  recover  their  tone 
sufficiently  to  do  without  it.  In  attending  to  the  evacuations  during 
the  first  twenty-four,  or  thirty-six  hours  after  labor,  the  patient  should 
never  be  allowed  to  rise  in  the  bed ;  it  has  often  been  the  case  that  a 
sudden  rising  up  in  bed,  within  a  day  or  so  after  delivery,  especially 
when  this  has  been  accompanied  with  hemorrhage,  has  been  followed 
by  immediate  death.  The  late  Professor  Meigs  considered  this  to 
arise  from  the  "heart  clot"  emboly.  The  excessive  loss  of  blood 
disposes  the  remaining  portion  of  this  fluid  circulating  in  the  system 
to  a  ready  coagulation;  consequently,  if  on  rising,  the  debilitated 
patient  should  faint,  the  activity  of  the  circulation  is  impeded,  and  a 
mass  of  coagulated  blood  forms  in  the  heart,  filling  it  so  that  the 
circulation  can  not  be  re-established,  and  death  must  ensue ;  or  if  this 
does  not  supervene,  restoration  takes  place  very  slowly,  with  symp- 
toms of  restlessness,  difficult  respiration,  and  a  peculiar  action  of  the 
heart.  Dr.  Meigs  says,  that  he  has  not  seen  a  patient,  struggling  and 
breathing  violently,  from  the  above  cause,  who  has  ever  recovered. 

The  condition  of  the  bowels  should  likewise  be  inquired  into ;  if  the 
patient  is  doing  well,  and  had  a  thorough  alvine  evacuation  previous 
to  delivery,  there  will  be  no  necessity  for  any  medication  in  two  or 
three  days,  if  at  all.  But,  if  the  bowels  were  costive,  or  if  there  are 
febrile  symptoms,  restlessness,  with  slight  pain  upon  pressure  of  the 
abdomen,  some  mild  laxative  medicine  should  be  administered.  If 
an  enema  can  be  given  without  worrying  or  exciting  the  patient  it 


ATTENTIONS    SUBSEQUENT    TO    DELIVERY. 

may  be  employed  in  preference  to  the  internal  laxative ;  but  on  no 
account  should  the  patient  be  actively  purged,  as  it  increases  her 
already  existing  debility,  favors  absorption  of  any  septic  poison  that 
may  be  present,  and  may  give  rise  to  some  uterine  displacement. 
Castor  Oil  is  the  agent  most  generally  employed  for  this  purpose,  but 
many  females  have  an  aversion  to  it,  consequently  other  laxatives  will 
have  to  be  used,  as  the  compound  powder  of  Rhubarb,  calcined  Mag- 
nesia, or  one  of  the  mild  aperient  waters  may  bo  substituted,  as 
Hunyadi.  Small  doses  of  Cascara  Cordial  is  a  favorite  with  many. 
In  fact,  any  one  of  the  mild,  non-irritating  laxatives  may  be  em- 
ployed, when  an  agent  of  the  kind  is  indicated.  I  have  frequently  been 
called  to  patients,  several  days  after  their  delivery,  who  were  suffering 
from  pains  in  the  abdomen,  headache,  restlessness,  and  febrile  symp- 
toms, caused  by  the  medical  attendant  having  neglected  to  evacuate 
the  bowels,  and  in  whom  all  these  symptoms  disappeared,  after  the 
action  of  a  dose  of  mild  purgative  medicine.  This  inattention  to  the 
condition  of  the  bowels  of  the  puerperal  female,  appears  to  constitute 
a  part  of  the  practice  of  a  certain  class  of  physicians.  It  is,  however, 
a  very  reprehensible  omission. 

The  LOCHIA  is  a  discharge  consisting  of  blood,  broken-down 
coagula,  and  decidual  debris,  which  takes  place  from  the  partially 
closed  vessels  of  that  part  of  the  uterine  surface  to  which  the  placental 
attachment  was  formed,  as  well  as  from  the  naked  surface  of  the 
uterus  deprived  of  its  decidual  membrane ;  it  generally  lasts  five  or 
six  days,  or  longer,  until  the  womb  is  restored  to  its  normal  size; 
though  with  some  females,  the  discharge  continues  until  the  re-appear- 
ance of  the  menses.  It  is,  at  first,  bloody,  but  in  twelve  or  thirteen 
hours  becomes  thinner  and  paler,  changing  to  a  discharge  of  bloody 
serum.  According  to  its  color,  the  lochia  is  distinguished  by  the 
names  of  sanguineous,  sero-sanguineous,  and  purulent  or  puriform; 
it  exhales  a  peculiar,  disagreeable  odor,  varying  in  intensity  with 
different  women,  which  is  called  gravis  odor  puerperii.  During  the 
milk-fever,  the  discharge  generally  ceases,  but  returns  on  its  subsid- 
ence, being  then  of  a  yellowish-white  color;  it  varies  in  quantity, 
being  with  some  women  very  small,  while  others  will  soil  from  six  to 
fifteen  napkins  in  the  twenty-four  hours;  but  this  quantity  gradually 
diminishes,  and  the  discharge  assumes  a  greenish  or  paler  color  before 
it  ceases.  The  lochial  discharge  serves  to  relieve  congestion,  and  to 
lessen  the  chances  of  an  inflammatory  attack;  during  fever,  it  becomes 


324  KING'S  ECLECTIC  OBSTETRICS. 

checked,  hence,  its  presence  is  indicative  of  the  absence  of  fever.  This 
flow  is  considered  to  bear  a  relation  to  the  expulsion  of  the  uterine 
contents,  somewhat  similar  to  that  which  exists  between  menstruation 
and  the  discharge  of  the  monthly  formed  decidua. 

Generally,  the  lochia  requires  no  interference ;  it  is  only  when  its 
condition  affects  the  health  of  the  patient,  that  medical  attention  will 
be  needed.  Thus,  it  may  be  very  small  in  quantity,  but  continue  the 
usual  time  without  any  unpleasant  results,  and  which  is  apt  to  occur 
after  flooding;  or  it  may  be  abundant,  and  cease  at  the  usual  time, 
without  any  detriment  to  health ;  or  it  may  stop  shortly  after  delivery, 
without  any  evil  consequences,  as  is  frequently  witnessed  in  the  case 
of  still-born  or  putrid  children.  When  this  flow  continues  beyond 
fourteen  or  sixteen  days,  it  is  indicative  of  existing  ulcerations  of  the 
cervix,  of  a  check  to  the  act  of  involution,  or  of  both.  Should  these 
conditions  be  found,  upon  examination,  to  exist,  astringent  solutions 
may  be  locally  applied  to  the  vaginal  walls  and  to  the  ulcerations,  as, 
of  Tannin,  Borax,  Chlorate  of  Potash,  Asepsin,  Persulphate  of  Iron, 
etc.;  while,  to  forward  uterine  involution,  agents  should  be  admin- 
istered internally  that  occasion  contraction  of  uterine  fiber,  as,  Ergot, 
Sulphate  of  Quinia,  Macrotys,  Cinnamon,  Strychnia,  etc. 

Sometimes,  however,  the  discharge  is  very  excessive,  producing 
much  debility;  in  these  cases,  remedies  must  be  employed  which  will 
diminish  the  quantity  of  the  flow,  as  well  as  strengthen  the  patient's 
system.  To  check  the  discharge,  astringents  may  be  employed;  Ma- 
crotys, Aletris,  Pulsatilla,  or  the  Parturient  Balm  may  be  'given,  as 
suited  to  each  particular  case.  Perchloride  or  Persulphate  of  Iron 
will  often  prove  serviceable,  in  dilute  solution.  I  have  also  gotten 
good  results  from  teaspoonful  doses  of  a  mixture  of  soluble  Citrate  of 
Iron ;  a  drachm  to  the  ounce  of  Port  wine.  As  tonics,  Quinine, 
preparations  of  Iron,  or  some  of  the  ordinary  vegetable  bitter  agents, 
may  be  used;  the  diet  of  the  patient  should  be  more  nourishing,  but 
not  stimulating,  and. she  should  be  kept  in  a  state  of  rest  and  quietude. 
If,  with  the  excessive  discharge,  there  is  vascular  excitement,  as  quick 
pulse,  heat  of  surface,  furred  tongue,  pain  in  the  back,  etc.,  the  patient 
should  be  placed  on  a  low,  mild  diet,  with  cooling  drinks,  the  bowels 
must  be  gently  moved  by  Seidlitz  Powders,  or  other  cooling  laxative, 
and  the  febrile  symptoms  may  be  overcome  by  the  administration  of 
Aconite,  Gelsemium,  or  such  other  specific  agents  that  may  be  espe- 
cially indicated,  prepared  as  usual,  in  the  half-glass  of  water,  and 
given  in  teaspoonful  doses,  every  one  or  two  hours.  Macrotys  will 


ATTENTIONS    SUBSEQUENT    TO    DELIVERY.  325 

be  often  called  for,  at  which  time  the  most  satisfactory  results  will 
follow  its  use ;  it  may  be  either  given  singly  or  with  the  sedative. 
Beside  the  sedative  and  antiphlogistic  influence  exerted  on  the  sys- 
tem by  these  agents,  we  also  obtain  the  peculiar  tonic  action  of  the 
Macrotys  upon  the  uterus,  thus  rendering  the  compound  a  highly  de- 
sirable one.  The  generative  parts  should  be  bathed  with  cool  water, 
three  or  four  times  a  day.  Should  the  increase  of  the  flow  be  owing 
to  the  presence  of  a  portion  of  the  placenta  within  the  uterine  cavity, 
and  which  may  be  presumed  if  the  discharge  is  offensive,  with  vomit- 
ing, the  vagina  may  be  syringed  two  or  three  times  daily  with  hot 
water,  in  which  may  be  used  Chlorate  of  Potash,  Borax,-  Asepsin,  or 
diluted  Carbolic  Acid,  one  to  fifty  or  sixty  parts  of  distilled  Water, 
or,  solution  of  Permanganate  of  Potash,  one  to  one  hundred  or  one 
hundred  and  twenty  parts,  etc.,  and  if  the  offending  portion  can  be 
easily  removed  it  should  be  done,  when  the  symptoms  are  very  urgent. 
Should  it  become  necessary  to  apply  any  of  these  to  the  inner  uterine 
walls,  it  must  be  effected  by  a  soft  uterine  probang,  and  not  by  injec- 
tion ;  the  greatest  circumspection  and  care  must  be  observed  in  mak- 
ing these  applications.  Generally,  however,  the  uterus  will  evacuate 
its  contents  with  more  safety  when  not  interfered  with  by  injections 
or  manual  operations.  ..-. 

At  times,  the  lochial  flow,  after  having  diminished  in  quantity,  sud- 
denly becomes  increased  and  of  a  red  color;  this  arises  from  the 
patient  sitting  up  too  soon,  or,  at  a  later  period,  from  too  much  exer- 
cise, as  of  walking.  Rest  in  the  recumbent  position  will,  usually,  be 
the  only  treatment  needed;  but  should  it  prove  obstinate,  the  red  dis- 
charge still  continuing,  secondary  hemorrhage  may  ensue,  for  which 
the  practitioner  must  be  prepared;  Ergot,  Cinnamon,  Macrotys,  Pul- 
satilla,  etc.,  are  among  the  articles  that  may  be  used  in  these  instances, 
together  with  a  confinement  to  the  horizontal  position.  Some  of  the 
astringent  preparations  of  Iron  may  frequently  be  employed  with 
benefit  in  these  cases. 

The  lochia  may  be  checked,  or  deficient  in  quantity,  from  other 
causes  than  uterine  contraction,  in  which  cases  febrile  symptoms  will 
be  present;  and  if  the  discharge  be  not  promptly  restored,  it  may 
form  the  basis  of  some  fatal  disease.  The  treatment  which  I  have 
found  to  be  most  commonly  beneficial,  is,  to  evacuate  the  bowels  by  a 
mild  purgative,  after  which  the  sedatives  and  other  agents  usually 
indicated  where  we  have  febrile  excitation  should  be  given  ;  at  the 
same  time  bathing  the  groins,  thighs,  and  inferior  extremities  with 


326  KING'S  ECLECTIC  OBSTETRICS. 

the  officinal  compound  tincture  of  Camphor  has  been  recommended. 
Hot  fomentations  to  the  abdomen  have  also  proved  serviceable. 

When  the  above  treatment  fails  to  remove  the  abnormal  symptoms, 
they  may  be  owing  to  inflammation  of  the  uterus,  or  other  local  in- 
flammation, which  will  require  to  be  treated  upon  general  principles. 
I  would  remark  here,  however,  that  the  combination  of  the  Sp.  Tr. 
of  Aconite  and  Macrotys,  above  mentioned,  with  attention  to  the  con- 
dition of  the  bowels,  and  warm  fomentations  to  the  abdomen,  have 
been  employed  in  my  own  practice  very  successfully.  I  have  also 
administered  the  tincture  of  Gelsemium,  in  these  cases,  with  the  most 
remarkable  results.  A  similar  course  may  be  pursued  where  the  dim- 
inution of  the  lochial  discharge  is  owing  to  uterine  rheumati-m  ; 
which  is  apt  to  be  the  case  when  the  uterus  is  attacked  by  this 
disease. 

Sometimes  the  lochia  has  a  very  fetid  odor,  is  acrid,  and  of  a  dark 
color;  this  may  be  owing  to  putrefaction  of  retained  coagula,  or  de- 
composition of  pieces  of  the  placenta  or  membranes  which  have  been 
left  within  the  uterus.  An  injection  of  hot  water,  with  the  addition 
of  an  astringent,  or  of  a  very  weak  solution  of  chloride  of  lime, 
passed  into  the  vagina  two  or  three  times  daily,  will  be  found 
sufficient  to  remove  the  fetor.  Or,  weak  solutions -of  Chlorinated 
Soda,  of  Permanganate  of  Potassa,  or  of  Carbolic  acid  may  be 
injected  into  the  vagina,  as  well  as  sprinkled  upon  that  part  of  the 
bed  in  the  vicinity  of  the  reproductive  organs.  When  the  discharge 
continues  of  a  purulent  character,  long  after  deliver}',  with  lumbar 
pains  and  sense  of  weight  accompanying,  it  may  be  owing  to  ulcers, 
or  abrasions  of  the  cervix  or  vagina,  which  will  have  to  be  determined 
by  the  speculum,  and  treated  accordingly.  When  the  lochia  is  acrid, 
an  infusion  of  Elm  bark  and  Black  Cohosh  root,  may  be  injected  into 
the  vagina,  several  times  a  day,  with  advantage. 

With  some  women  the  secretion  of  milk  is  attended  with  considerable 
vascular  excitement;  rigors,  headache,  pains  in  the  back  and  limbs, 
quick  pulse,  furred  tongue,  etc.,  are  present  in  a  greater  or  less  degree. 
This  condition  is  termed  milk-fever,  and  is  by  no  means  common  to 
every  parturient  woman ;  it  usually  manifests  itself  in  two  or  three 
days  after  delivery;  occasionally  sooner,  and  sometimes  later.  It  may 
generally  be  avoided  by  placing  the  child  to  the  breast  as  soon  after 
labor  as  is  compatible  with  the  strength  and  condition  of  the  mother, 
and  by  the  early  administration  of  a  mild  purgative.  It  commonly 


ATTENTIONS    SUBSEQUENT    TO    DELIVERY.  327 

lasts  for  twelve  or  twenty-four  hours,  rarely  forty-eight,  and  may  be 
overcome  by  the  use  of  cooling  purgatives,  fomentations  to  the  breasts, 
if  they  are  full,  hard,  and  painful,  and  the  frequent  application  of  the 
child.  "When  very  severe,  diaphoretics  or  sedatives  may  also  be  given. 
When  the  rigors  are  very  intense,  or  when  the  fever  assumes  peri- 
odicity, febrifuges  and  antiperiodics  must  be  administered,  and  the 
practitioner  should  be  on  his  guard  lest  it  be  attended  with  puerperal 
peritonitis. 

Milk-fever  is  often  occasioned,  or  aggravated  by  too  long  a  delay 
in  giving  suck  to  the  child,  and  which  may  arise  from  deficient,  mal- 
formed, or  sore  nipples.  Where  the  nipples  are  deficient  or  mal- 
formed, the  milk  will  have  to  be  extracted  by  artificial  means,  as  the 
breast-pump.  The  secretion  of  milk  is  liable  to  become  diminished 
when  the  uterus  is  suffering  under  a  rheumatic  attack;  and  this, 
together  with  the  severe  pain,  diminution  of  lochia,  pain  on  pressure, 
etc.,  may  be  readily  taken  for  peritonitis.  From  recent  investi- 
gations it  seems  more  probable  that  the  symptoms,  to  which  the 
name  of  "milk-fever"  has  been  applied,  are  in  no  wTay  associ- 
ated with  the  secretion  of  milk,  but  are  rather  the  result  of  a 
mild  form  of  puerperal  septicemia  arising  from  absorption  of  any 
putrid  lochia  that  may  be  present  within  the  uterus  or  vagina,  and 
may  be  remedied  by  keeping  up  proper  uterine  contraction,  with 
cleanliness,  antiseptics,  and  tonics  or  febrifuges  as  required. 

Excoriation  and  ulceration  of  the  nipplqs  is  a  very  common  aifection 
among  nursing  women,  indeed,  some  suffer  severely  from  it  after  every 
confinement.  It  is,  sometimes,  so  severe  and  painful  that  it  is  impos- 
sible to  bear  the  application  of  the  child's  mouth  to  the  nipple,  and, 
in  some  instances,  a  persistence  in  suckling,  gives  rise  to  large,  foul,, 
painful,  superficial  ulcers,  or  deep  cracks,  which  bleed  upon  every 
application,  of  the  child ;  occasionally,  the  woman  loses  her  nipple. 
This  difficulty  may  be  obviated,  by  the  use  of  artificial  shields,  or 
prepared  teats,  which  can  be  had  in  every  drug-store;  but  frequently 
the  child  refuses  to  suck  with  them,  and  the  aid  of  the  physician  is 
demanded.  Whenever  inflammation  is  present,  it  must  first  be  subdued, 
previous  to  the  application  of  any  healing  salve  or  ointment.  This 
may  be  effected  by  a  poultice  of  Elm  bark,  or  Flaxseed,  which  should 
cover  the  whole  nipple  and  areola",  after  which  any  of  the  preparations 
named  below  may  be  applied.  Sometimes,  the  inflammation  will  be 
so  intense,  as  to  require  the  application  of  a  few  leeches  on  the  breast 
outside  of  the  areola,  before  any  benefit  will  result  from  the  emollient 
poultices.  The  severe  pain  may  frequently  be  relieved  by  a  careful 


328  KING'S  ECLECTIC  OBSTETRICS. 

application  of  a  solution  of  Nitrate  of  Silver  to  the  excoriated  parts 
only ;  the  solution  may  be  of  the  strength  of  from  two  to  six  Drains 
of  salt  to  the  fluiclounce  of  water. 

After  the  reduction  of  the  inflammation,  and  in  those  cases  where 
it  is  but  slight,  the  following  applications  have  been  recommended  : 
1.  Take  of  Spermaceti  Ointment,  six  drachms;  Balsam  of  Peru,  ono 
drachm;  mix  together,  and  apply  a  small  portion  to  the  nipples,  several 
times  a  day.  2.  Take  of  Mutton  Suet,  one  ounce;  Balsam  of  Peru, 
two  drachms ;  Honey,  Glycerin,  of  each,  one  drachm ;  melt  the  Suet, 
and  add  the  remainder  of  the  articles,  stirring  well  together.  I  Rw 
same  as  above.  3.  Take  of  Balsam  of  Tolu,  Balsam  of  Peru,  Honey, 
of  each,  fourteen  drachms;  Camphor,  Opium,  of  each,  two  drachms; 
Alcohol,  two  pints ;  mix  together  and  allow  them  to  stand  for  seven 
days,  frequently  agitating  them.  A  piece  of  linen  is  to  be  moistened 
with  this,  and  kept  constantly  applied  to  the  nipple  when  the  child  is 
not  suckling;  if  too  severe,  it  may  be  slightly  diluted  with  water.  It 
must  be  washed  off  every  time  previous  to  the  application  of  the  child. 
I  have  used  this  successfully,  in  many  cases.  4.  Take  of  Beef-mar- 
row, Olive  Oil,  white  Wax,  of  each  two  ounces;  Cherry  Wine,  made 
of  common  cherries  (Cerasus  avium,  C.  vufgarus,  etc.),  two  fluidounees  ; 
place  the  articles  together  in  a  vessel,  apply  it  over  a  gentle  heat,  and 
allow  it  to  remain  until  all  the  wine  has  evaporated.  This  ointment 
may  be  applied  just  previous  to  the  child's  suckling,  and  immediately 
after.  Should  the  child's  mouth  be  sore,  this  will  have  a  tendency  to 
heal  it.  It  forms  an  elegant  preparation,  one  which  I  have  su< 
fully  employed  in  the  most  distressing  and  obstinate  cases.  And  as 
my  object  is  to  render  this  work  one  of  practical  utility,  even  in  minor 
difficulties,  I  do  not  hesitate  to  give  publicity  to  these  small  details. 
5.  Take  of  Glycerin,  Tannin,  each,  two  drachms;  mix,  dissolve  the 
Tannin,  and  apply  frequently.  6.  Take  of  Gum  Tragacanth,  8  to  15 
parts;  Lime  water,  120  parts;  Glycerin,  30  parts;  Rose  water,  100 
parts ;  mix,  and  employ  in  ointment  or  embrocation.  The  agents  I  more 
commonly  employ  are,  however,  No.  3,  of  the  preceding,  and  diluted 
Carbolic  acid,  or  Carbolate  of  Soda.  I  have  frequently  been  called 
upon  to  prescribe  in  cases  of  sore  nipples,  which  had  baffled  the  treat- 
ment of  four  or  five  preceding  medical  attendants,  but  which  yielded 
at  once  to  the  course  above  named.* 

*  The  above  named  form nlse  are  old;  most  of  them  are  taken  from  the  Am.  Dis- 
pensatory. They,  however,  will  be  found  quite  efficient,  and  may  be  used  where 
other  means  fail.  A  cure,  in  most  cases,  will  follow  the  application  of  Glycerole  of 
Tannin. 


ATTENTIONS    SUBSEQUENT    TO    DELIVERY. 

After  having  bestowed  the  proper  attentions  to  the  mother,  and 
Ascertained  the  condition  of  the  bowels,  bladder,  uterus,  lochia,  pulse, 
breasts,  etc.,  the  practitioner  may  then  inquire  concerning  the  child. 
Whether  it  has  had  evacuations  from  the  bowels  and  bladder,  and 
whether  it  sucks.  In  cases -where  the  urine  is  scanty,  or  where  there 
has  been  no  urinary  discharge,  and  the  parts  are  natural,  requiring  no 
surgical  operation,  a  warm  bath,  cold  water  sprinkled  upon  the  hypo- 
gastrium,  or  the  administration  of  one  of  the  diuretic  infusions, 
will  be  very  serviceable;  if,  however,  these  do  not  cause  a  copious 
urinary  discharge,  and  the  hypogastric  region  be  swollen  from 
accumulation  of  fluid  in  the  urinary  bladder,  it  may  become  neces- 
sary to  introduce  a  small  flexible  catheter,  in  order  to  remove  the 
urine,  and  which  will  be  found  a  difficult  operation,  requiring  great 
care.  If  the  bowels  have  not  been  evacuated,  and  there  is  no  imper- 
forate  anus  requiring  the  surgeon's  aid,  a  mild  laxative  as  before 
remarked,  may  be  given ;  Castor  Oil  is  usually  preferred,  though  I 
prefer  Sweet  Oil  in  almost  every  instance.  The  light  should  not  be 
too  intense  for  the  delicate  eyes  of  the  child,  but  should  be  kept  sub- 
dued for  several  days  after  birth,  gradually  accustoming  these  organs 
to  ordinary  daylight.  The  clothing  of  the  child  should  be  warm,  and 
loosely  applied,  that  it  may  be  free  in  its  motions;  caps  are  to  be 
avoided  as  injurious;  the  dress  should  be  high  up  on  the  neck,  with 
long  sleeves ;  and  the  diapers  must  be  soft,  and  never  allowed  to 
become  dry  and  stiffen  with  the  excretions,  and  thus  give  rise  to 
troublesome  excoriations. 

The  only  proper  food  for  an  infant,  is  its  mother's  milk,  and  when 
this  can  be  obtained,  little  else  should  be  given  it,  for  at  least  six  or 
seven  months.  All  paps,  panadas,  gruels,  and  cordials  are  to  be 
avoided,  and  their  use  among  infants,  as  food,  can  not  be  too  severely 
censured.  Colics,  diarrheas,  green  and  watery  stools,  and  severe 
aphthous  affections  are  the  penalties  of  such  unnatural  practices. 
When  the  mother's  milk  can  not  be  had,  from  \vhatever  cause,  and 
a  wet  nurse  is  not  at  hand,  and  it  becomes  necessary  to  feed  the  child, 
a  mixture  of  one  part  of  water  to  two  or  three  parts  of  cow's  milk, 
and  warmed,  forms  an  excellent  substitute  for  the  parent  fluid.  The 
milk  used  should  be  procured  from  one  healthy  cow  regularly,  and  bo 
given  as  soon  as  possible  after  it  has  been  milked  out.  The  addition 
of  cane  sugar  to  the  preparation,  as  advised  by  some  writers,  I  con- 
sider uncalled  for  and  pernicious,  frequently  producing  diseases  of 
the  stomach  and  bowels,  which  are  attributed  to  other  causes.  If 
sugar  is  at  all  desired  as  an  addition,  it  should  be  sugar  of  milk  alone. 


330  KINGS    ECLECTIC   OB8TETBICS.' 

The  following  table,  by  Simon,  showing  the  mean  of  fourteen  analyses, 
made  at  different  periods,  with  the  milk  of  the  same  woman,  and 
which  very  nearly  corresponds  with  the  analyses  of  other  investigators, 
will  conclusively  show  the  folly  of  adding  sugar  to  a  preparation 
intended  to  supply  the  place  of  breast-milk : 

Water 883.6 

Solid  constituents 116.4 

Butter 25.3 

Casein 34.3 

Sugar  of  milk,  and  extractive  matters 48.2 

Fixed  salts 2.3 

And  as  to  the  sugar  of  milk,  it  very  nearly  corresponds  in  quantity 
to  that  of  cow's  milk,  as  may  be  seen  by  the  following  analysis  of  this 
animal's  milk,  by  Chevallier  and  Henri : 

Casein 4.48 

Putter 3.13 

Sugar  of  milk 4.77 

Saline  matter 0.60 

Water 87.02 

It  will  be  observed  that  cow's  milk  contains  more  casein  and  butter 
than  human  milk,  which  may,  probably,  lead  to  the  production  of  a 
still  better  substitute  for  this  last,  than  the  one  proposed  above. 

In  feeding  the  child  its  artificial  food,  it  should  be  done  in  a  manner 
to  simulate,  as  closely  as  possible,  the  natural  functions;  that  is,  it 
should  not  be  fed  with  a  spoon,  but  should  be  taught  to  suck  from 
a  vessel,  through  some  porous  substance,  by  which  means  the  saliva  is 
invited  into  the  mouth  to  be  swallowed  with  the  food,  which  latter  is 
thereby  rendered  more  easily  digestible. 

The  parturient  woman  should  be  kept  in  a  state  of  rest  and  quiet 
for  nine  or  ten  days,  in  order  that  the  process  of  involution  may 
progress  uninterruptedly,  or  in  other  words  that  the  uterus  may  return 
to  its  non-gravid  size,  without  hemorrhage,  inflammation,  or  displace- 
ment, and  that  the  system  may  fully  recover  from  the  shock  given 
to  it  by  the  labor.  The  first  two  or  three  days,  she  must  not  be 
allowed  to  remove  from  the  horizontal  position  (though  she  may 
move  around  in  bed),  especially  if  the  labor  has  been  protracted,  or 
if  there  has  been  hemorrhage ;  after  this  time,  if  not  contra-indicated, 
she  may  be  permitted  to  sit  up  in  bed  a  few  minutes  at  a  time,  or  in  a 


ATTENTIONS    SUBSEQUENT    TO    DELIVERY.  331 

chair,  while  the  bed  is  being  fixed,  and  should  from  this  time  lengthen 
the  duration  of  sitting  each  day,  until  there  is  no  further  occasion  for 
remaining  in  the  bed.  But  in  this  matter,  the  judgment  of  the 
accoucheur  based  upon  the  conditions  present  must,  after  all,  decide 
the  proper  degree  of  motion  to  allow  the  patient;  some  strong,  healthy 
women  may  sit  up  and  even  walk  about  in  a  day  or  two  subsequent  to 
labor,  while  delicate  and  weak  females,  or  those  who  have  been  much 
enfeebled  by  a  prolonged  labor,  hemorrhage,  etc.,  will  require  rest  and 
quiet  in  the  recumbent  position  for  three  or  four  days,  or  even  longer. 
Too  much  rest  in  bed  relaxes  muscular  fiber  and  weakens  nerve 
power,  while  proper  movements  tend  to  equalize  the  circulation,  to 
remove  passive  uterine  congestion,  and  to  excite  the  contractile  power 
of  the  uterus  sufficiently  to  enable  it  to  expel  any  putrid  lochial  clots 
that  may  form  within  its  cavity,  and  thereby  tend  to  the  avoidance 
of  septicaemia.  Where  there  is  a  sense  of  fatigue,  weariness,  mild 
stimulation  will  prove  beneficial. 

The  room  should  be  well  ventilated1,  but  without  exposing  the 
patient,  and  be  kept  clean,  quite  free  from  all  unpleasant  odors,  and 
moderately  warm.  The  female  should  be  kept  clean,  especially  about 
the  genitals,  which  must  be  frequently  bathed  with  lukewarm  water, 
or  warm  water  and  spirits;  and  her  diet  must  be  light,  nutritious,  and 
of  easy  digestion,  especially  during  the  first  days.  Gruel,  mush  and 
milk,  toast,  panada,  arrowroot,  rice,  etc.,  are  all  that  is  usually  per- 
mitted until  the  fifth  or  sixth  day,  when,  if  she  be  doing  well,  the 
use  of  soft-boiled  eggs,  oysters,  and  weak  soups,  may  be  allowed. 
After  the  tenth  day,  and  during  the  puerperal  month,  animal  food, 
fowls,  and  other  diet  of  a  nourishing  but  non-stimulating  character, 
may  be  given;  if  she  be- weak,  a  little  porter  will  be  admissible. 
However,  it  will  more  frequently  be  found  that  a  compliance  with  the 
desires  of  the  patient,  as  to  diet,  will  answer  a  much  better  purpose, 
than  any  arbitrary  rules  that  can  be  laid  down,  when  such  desires  are 
not  morbid  or  otherwise  contraindicated. 

If  the  patient,  previous  to  pregnancy,  was  afflicted  with  prolapsus 
uteri,  an  intermittingly  continued  recumbent  position  [but  not  neces- 
sarily in  bed]  for  eight  or  ten  weeks  after  delivery,  together  with 
Sulphate  of  Quinia,  Macrotys,  Pulsatilla,  Aletris,  Strychnia,  etc.,  in- 
ternally, according  to  the  indications  [to  improve  the  tone  and  con- 
dition of  the  uterus],  will  contribute  much  toward  a  radical  cure; 
the  medical  man  observing  that  the  uterus  is  kept  in  position  during 
the  intervals  of  sitting  or  standing. 

The  visits  of  the  practitioner  should  be  daily,  for  the  first  two  or 


332  KING'S  ECLECTIC  OBSTETRICS. 

three  days,  or  oftener,  if  required  ;  after  which,  a  visit  every  second  or 
third  day,  made  on  two  different  occasions,  will  be  sufficient  in  ordinary 
cases.  However,  this  is  governed  by  custom ;  in  some  places,  after  the 
first  visit  succeeding  delivery,  no  other  is  made,  unless  the  physician  is 
sent  for;  in  others,  the  visits  are  continued  more  or  less  often,  as  may  be 
required,  until  the  ninth  or  tenth  day.  I  consider  the  last-named  plan 
of  visiting,  the  preferable  one,  both  as  regards  the  safety  of  the  woman, 
and  the  reputation  of  the  accoucheur.  If,  after  the  fourth  or  fifth 
week  from  parturition,  the  patient  suffers  from  pains  in  the  back  and 
loins,  debility,  profuse  leucorrhea,  irritable  bladder,  with  more  or  less 
straining  and  tenesmus,  and  perhaps  some  hemorrhage,  we  may  be  led 
to  suspect  defective  involution,  and  if  examination  confirms  our 
suspicion,  we  should  at  once  pursue  the  treatment  necessary  to  remove 
the  subinvolution,  which  consists,  in  some  cases,  of  gently  stimulat- 
ing vaginal  injections,  together  with  uterine  tonics,  as  Macrotys, 
Pulsatilla,  Aletris,  Parturient  Balm,  etc. 


CHAPTER   XXVII. 

PRESENTATIONS    AND    POSITIONS. 

FOR  the  purpose  of  more  clearly  understanding  the  mechanism  of 
labor,  it  is  necessary  that  a  knowledge  of  the  various  presentations  and 
positions  of  the  fetus,  be  had.  By  the  term  presentation,  in  obstetrics, 
is  meant  the  part  of  the  fetus  which  occupies  the  pelvic  superior  strait 
at  the  commencement  of  labor;  while  position  designates  the  relations 
which  the  presenting  part  assumes  with  the  circumference  of  this  strait, 
or  with  some  fixed  point.  Thus,  if  it  is  said  the  vertex  present*,  we 
understand  it  to  mean  a  presentation  of  the  head,  in  which  the  head 
of  the  child  will  be  the  part  first  delivered  ;  if  it  is  still  further  said, 
that  it  is  in  the  left  occipito-anterior  position,  we  learn  that  the  occiput 
of  the  child  looks  toward  the  left  acetabulum  of  its  mother,  while  its 
forehead  is  toward  her  right  sacro-iliac  symphysis,  and  the  sagittal 
suture  will  consequently  be  found  running  in  an  oblique  direction  in 
the  pelvis  between  these  two  points — or,  in  other  words,  we  have  the 
position  in  which  the  head  presents. 

There  are  two  PRESENTATIONS  recognized  in  obstetrics— one 


PRESENTATIONS    AND    POSITIONS. 


333 


Cephalic,  the  other  Pelvic.  The  cephalic,  is  divided  into  vertex,  face, 
and  shoulder  presentations;  the  pelvic,  into  breech,  knees,  and  feet. 
Occasionally,  some  portion  of  the  trunk  may  present,  or  perhaps  the 
ear  and  side  of  the  head,  but  these  are  so  extremely  rare,  as  to  form 
exceptions  rather  than  exemplifications ;  and  their  management  would 
be  similar  to  that  recommended  for  arm  or  shoulder  presentations. 

The  most  common,  as  well  as  the  most  favorable  presentation  for 
both  mother  and  child,  is  that  of  the  vertex  or  head,  and  which  alone 
constitutes  a  natural  labor ;  the  others  are  only  deviations.  That  this 
is  the  fact  may  be  gathered  from  the  following  statistics :  Bland 
records  1792  head  presentations  in  1897  cases  of  labor;  Dubois  10,262 
in  10,742;  Kluge  257  in  298;  Lovati  61  in  67;  Mazzini  439  in  452; 
Nfflgele  1210  in  1296;  Pacord  49  in  53;  Ramoux  266  in  275;  Riecke 
214,134  in  219,258;  Siebold  132  in  137;  Smellie  920  in  1000;  and 
Velpeau  392  in  400. 

The  relative  frequency  of  the  various  presentions,  are  given  in  the 
following  table,  taken  from  Churchill's  Obstetrics, 


Author. 

Total  No.  of 
cases. 

Head  presen- 
tations. 

Breech  pre- 
sentations. 

Inferior  ex- 
tremities. 

Superior  ex- 
tremities. 

20  517 

19  810 

372 

238 

80 

Mad    La  Chapelle  

15652 

14677 

349 

255 

68 

Dr  Jos   Clarke  

10  387 

9  748 

61 

184 

48 

DP    Merriman  

2947 

2735 

78 

40 

19 

Dr  Granville  

640 

619 

2 

3 

1 

Edin  Hospital    

2452 

2  225 

17 

8 

4 

Dr.  Maunsell  

839 

786 

21 

4 

691 

645 

14 

7 

4 

Dr.  Collins  

16414 

15912 

242 

187 

40 

Dr   Beatty...  

1  182 

1  105 

28 

15 

4 

4666 

4  266 

59 

29 

12 

Dr   Churchill  

1  640 

1  119 

35 

22 

9 

The  POSITIONS  of  the  two  presentations  and  their  divisions  or 
deviations,  vary  considerably,  so  much  .so  that  some  authors  have 
given  one  hundred  and  two  distinct  positions.  (Baudelocque.}  But 
these  have  recently  been  so  reduced  and  simplified  by  Nsegele,  Dubois, 
Stoltz,  and  other  accoucheurs,  that  the  whole  of  them  may  be  com- 
prised in  sixteen  positions,  and  which  will  be  found  fully  sufficient  for 
all  practical  purposes.  The  many  slight  alterations  and  deviations 
in  position,  which  may  occur  with  the  several  presentations,  and  which 
have  given  rise  to  the  numerous  positions  above  referred  to,  may, 
singly,  either  be  reduced  to  some  one  of  the  distinct  positions,  here- 
inafter named,  before  the  termination  of  labor,  or  may  hold  such 


334  KINCi'.S    KCLKCTIC    OI5STETRICS. 

a  close  relation  to  it,  as  to  require  no  material  difference  in  its  man- 
agement. 

In  a  VERTEX  or  CRANIAL  PRESENTATION,  although  it 
mav  become  necessary  to  determine  the  situation  of  the  anterior  and 
|H.-ierior  fontanelles,  and  the  direction  assumed  by  the  sagittal  suture, 
in  order  to  ascertain  its  position,  yet  it  is  the  posterior  fontanelle  alone, 
which  distinguishes  the  situation  of  the  occiput;  and  this  fontanelle,  in 
all  natural  labors,  is  the  most  readily  reached  by  the  finger.  A  vertex 
position  is  characterized  by  the  relation  existing  between  the  occiput 
of  the  fetus,  and  the  acetabulum,  symphysis  pubis,  or  sacro-iliac  sym- 
physes  of  the  maternal  pelvis.  Thus,  then,  the  positions  of  a  vertex 
presentation,  may  be  arranged  as  follows : 

POSITIONS  OF  THE  VEKTEX  OR  CRANIAL  PRESENTATION. 

1st.  LEFT  OCCIPITO-ANTERIOR,  in  which  the  occiput  of 
the  child  looks  toward  the  left  acetabulum  of  the  mother,  or  anteriorly 
and  to  the  left  of  the  pelvis.  In  this  position  the  forehead  of  the 
child,  and  consequently  the  anterior  fontanelle,  will  be  found  toward 
the  right  sacro-iliac  symphysis,  the  sagittal  suture  running  obliquely 
across  the  pelvis  anteriorly  from  the  left,  to  the  right  posteriorly. 
This  position  has  also  been  called  the'  left  occipito-cotyloid,  or  first 
(oblique)  cranial  position.* 

2d.  RIGHT  OCCIPITO-ANTERIOR,  in  which  the  occiput  of 
the  child  looks  toward  the  right  acetabulm  of  the  mother,  or  ante- 
riorly and  to  the  right  of  the  pelvis.  In  this  position,  the  anterior 
fontanelle  will  be  found  toward  the  left  sacro-iliac  symphysis,  the 
sagittal  suture  running  obliquely  across  the  pelvis  anteriorly  from  the 
right,  to  the  left  posteriorly.  This  position  has  also  been  called  the 
right  occipito-cotyloid,  or  second  (oblique)  cranial  position. 

3d.  OCCIPITO-PUBAL,  in  which  the  occiput  faces  the  sym- 
physis pubis  of  the  mother,  or  is  placed  anteriorly  without  any  lateral 
obliquity.  In  this  position,  the  anterior  fontanelle  will  be  toward  the 

*  I  see  no  necessity  for  .the  changes  in  name  which  some  authors  have  given  for  the 
varions  positions  in  which  the  head,  or  other  parts  of  the  fetus,  may  present.  The 
names  which  I  still  adhere  to,  and  which  originated  with  eminent  obstetricians,  appear 
to  me  to  convey  a  clearer  and  much  better  understanding  of  the  positions  than  any 
others  that  have  yet  been  proposed  as  substitutes.  Indeed,  the  new  terms  attempted 
to  be  introduced  by  recent  writers  are  not  only  more  apt  to  confuse  the  student  and 
practitioner,  but  are,  certainly  to  my  mind,  very  unsatisfactory.  The  term  left  occipito- 
anterior,  will  much  better  convey  to  the  mind  of  the  accoucheur  the  fact  that  the  occi- 
put is  to  the  left  anteriorly,  than  the  term  first  cranial  position. — K. 


PRESENTATIONS   AND   POSITIONS.  335 

sacrum,  the  sagittal  suture  running  in  the  direction  of  the  antero- 
posterior  diameter  of  the  pelvis.  This  position  has  also  been  called 
the  first  (direct)  cranial  position. 

4th.  LEFT  OCCIPITO-POSTERIOR,  in  which  the  occiput 
looks  toward  the  left  sacro-iliac  symphysis  of  the  mother,  or  poste- 
riorly and  to  the  left  of  the  pelvis.  In  this  position,  the  forehead  of 
the  child,  or  its  anterior  fontanelle,  will  be  found  toward  the  right 
acetabulum,  the  sagittal  suture  running  obliquely  across  the  pelvis 
anteriorly  from  the  right,  to  the  left  posteriorly  as  in  the  second  posi- 
tion. This  position  has  also  been  called  the  right  fronto-cotyloid,  or 
third  (oblique)  cranial  position. 

5th.  RIGHT  OCCIPITO-POSTERIOR,  in  which  the  occiput 
looks  toward  the  right  sacro-iliac  symphysis  of  the  mother,  or  poste- 
riorly and  to  the  right  of  the  pelvis.  In  this  position,  the  forehead 
of  the  child,  or  its  anterior  fontanelle,  will  be  toward  the  left 
acetabulum,  the  sagittal  suture  running  obliquely  across  the  pelvis 
anteriorly  from  the  left,  to  the  right  posteriorly,  as  in  the  first  posi- 
tion. It  has  also  been  called  the  left  fronto-cotyloid,  or  fourth  (oblique) 
cranial  position. 

6th.  OCCIPITO-SACRAL,  in  which  the  occiput  faces  the  sacrum 
of  the  mother,  or  is  placed  posteriorly  without  any  lateral  obliquity. 
In  this  position  the  anterior  fontanelle  will  be  found  toward  the 
symphysis  pubis,  the  sagittal  suture  being  in  the  same  direction  as  in 
the  third  position.  This  has  also  been  called  the  second  (direct)  cranial 
position. 

The  student  can  readily  master  a  knowledge  of  these  positions,  if, 
taking  the  vertex  or  occiput  as  the  guide,  he  will  bear  in  mind,  that  it 
may  be  placed  either  anteriorly  or  posteriorly  in  the  maternal  pelvis, 
and  that,  commencing  with  its  anterior  position  as  the  first,  he  has 
merely  to  give  to  it  the  directions,  left,  right,  and/row^.  Thus,  vertex 
to  the  left  anterior,  vertex  to  the  right  anterior,  vertex  anterior,  vertex 
to  the  left  posterior,  vertex  to  the  right  posterior,  and  vertex  posterior. 
Professor  Meigs  simplifies  the  positions,  the  better  to  impress  them 
upon  the  student's  mind,  thus :  "  vertex  left,  vertex  right,  vertex 
front;  forehead  left,  forehead  right,  forehead  front,"  and  which 
enumeration  is,  undoubtedly,  as  he  remarks,  "  the  easiest  one  to 
remember."  The  importance  of  a  knowledge  of  these  positions,  is, 
that  in  cases  where  an  interference  is  demanded,  the  accoucheur  may 
have  a  certain  guide  by  which  to  govern  his  operations,  with  an  eye  to 
the  safety  of  the  mother,  as  well  as  of  the  child ;  and,  without  this 
knowledge,  any  assistance  which  may  be  attempted,  is  more  likely  to 


336  KING'S  ECLECTIC  OBSTETRICS. 

effect  mischief  than  benefit.  And  I  hold  a  man,  who  is  ignorant  of 
these  matters,  criminally  responsible  for  any  fatal  consequences  that 
may  follow  his  rash  attempts  to  accomplish — he  knows  not  what.  Nor 
is  the  excuse,  "that  he  has  no  malice  or  evil  feeling  toward  his  patient, 
but  was  endeavoring  to  do  the  best  he  could  for  her,"  a  valid  one — he 
has  no  right,  whatever,  even  with  the  authority  of  a  diploma,. to  under- 
take a  practice  which  concerns  health  and  life,  with  an  entire  ignorance 
of  his  duties;  the  very  attempt  alone,  is,  in  my  estimation,  criminal. 

More  recently  writers  have  given  but  four  positions,  the  first  or  left 
occipito-anterior;.  the  second  or  right  occipito-anterior;  the  third  or 
left  occipito-posterior;  and  the  fourth,  or  right  occipito-posterior. 
The  other  positions,  four  in  number,  occipito-pubal  or  sacral,  and  left 
or  right  transverse  vertex  positions,  from  their  rare  occurrence,  and 
from  the  fact  that  they  must  assume  an  oblique  position  before  the 
head  can  be  born,  unless  it  be  very  small  as  compared  with  the  maternal 
pelvis,  are  merely  referred  to.  Yet  as  the  first  mentioned  do  sometimes 
occur,  I  think  it  proper  to  recognize  them.  The  transverse  positions, 
as  far  as  my  own  experience  is  concerned,  are  nothing  more  than 
positions  which  are  incidentally  encountered  during  the  movement  of 
the  head  toward  an  oblique  position. 

When  the  head  presents  well  flexed,  it  is  a  vertex  presentation,  but 
when  extension  has  occurred,  it  then  becomes  a  FACE  PRESENTA- 
TION, in  which  but  two  positions  are  recognized.  In  the  diagnosis 
of  face  positions,  the  mentum  or  chin  of  the  child,  must  be  taken  as 
the  guide. 

Although  the  labor  in  face  presentations  is  tedious,  and  more  painful 
to  the  mother,  and  somewhat  more  dangerous  for  the  child  than  in 
vertex  presentations,  yet  we  find  that  in  the  majority  of  cases  they 
terminate  naturally,  and  without  any  artificial  aid.  From  statistics 
collected  from  French,  German,  and  English  authorities,  it  appears 
that  in  136,123  cases,  the  face  presented  in  640  or  about  1  in  21 2| 
cases,  so  that  these  deviations  of  the  natural  vertex  presentation  are 
very  rare.  As  to  the  labor,  we  have  a  record  of  344  cases,  in  which 
248  were  delivered  naturally,  42  required  version,  20  the  forceps,  and 
15  craniotomy.  The  mortality  to  the  mother  averages  about  1  in  50 ; 
to  the  child  1  in  7;  and  it  has  been  found  the  greatest  to  both  mother 
and  child  in  those  cases  where  assistance  was  given ;  so  that  the 
necessity  for  interference  is  not  so  great  as  was  formerly  supposed. 


PRESENTATIONS   AND    POSITIONS.  337 

POSITIONS  OF  FACE  PRESENTATIONS. 

1st.  LEFT  MENTO-ILIAC,  in  which  the  child's  chin  is  to  the 
left  side  of  the  maternal  pelvis,  and  its  forehead  to  the  right  side. 
This  is  also  termed  the  second  or  left  face  position. 

2d.  EIGHT  MENTO-ILIAC,  in  which  the  chin  of  the  child  is  to 
the  right  side  of  the  mother's  pelvis,  and  its  forehead  to  her  left  side. 
This  is  also  termed  the^rs^  or  right  face  position. 

Some  authors  give  two  other  positions,  one  the  mento-sacral  or  fourth 
face  'position,  in  which  the  chin  is  toward  the  sacrum  or  nearly  so,  and 
the  forehead  toward  the  pubic  symphysis,  and  the  other,  the  mento-pubic 
or  third  face  position,  exactly  the  reverse  of  the  preceding  one.  The 
former  is  said  to  be  extremely  rare,  and  I  very  much  doubt  whether  it 
can  occur,  except  in  children  with  very  small  heads,  or  in  premature 
labors.  The  latter  is  likewise  seldom  met  with,  although  it  is  the 
position  which  the  two  principal  positions  assume  at  the  termination 
of  labor.  For  practical  purposes  the  two  positions  above  named  are 
sufficient.  The  right  mento-iliac  position  is  much  more  frequently 
encountered  than  the  left,  and  is  commonly  given  by  authors  as  the 
first  face  position  ;  but,  as  I  have  commenced  with  the  vertex  presenta- 
tion by  giving  the  first  position  to  the  left,  and  the  second  to  the  right, 
I  have  considered  it  better  to  adhere  to  this  arrangement  with  all 
presentations  without  regard  to  the  frequency  of  any  one  position 
among  them,  and  which  certainly  presents  more  uniformity  and  less 
complexity. 

A  SHOULDER  PRESENTATION  may  be  considered  a  deviation 
of  the  cephalic  presentation,  and  includes  those  of  the  arm,  elbow,  and 
hand;  according  to  statistics  it  has  occurred  358  times  in  93,398  cases, 
or  about  I  in  260f,  and  its  mortality  to  the  mother  is  about  1  in  9, 
while  of  the*  children  rather  more  than  one-half  have  been  lost.  There 
are  four  shoulder  positions;  two  for  each  shoulder,  and  the  points  by 
which  the  practitioner  is  to  be  guided  in  his  diagnosis,  are,  the  head  of 
the  fetus,  and  the  ilium  of  the  mother ;  some  authors  name  the  back 
of  the  fetus  instead  of  its  head,  while  others  again  have  two  dorso- 
anterior,  and  two  abdomino-anterior  positions.  The  right  arm  or 
shoulder  presents  oftener  than  the  left,  and  in  the  majority  of  instances, 
the  back  of  the  fetus  will  be  looking  toward  the  maternal  abdomen. 
First,  is  the  distinctive  term  applied  to  the  two  positions  of  the  right 
shoulder  presentation  :  and  second,  to  those  of  the  left. 
22 


338  KING'S  ECLECTIC  OBSTETRICS. 

POSITIONS  OF  SHOULDER  PRESENTATIONS. 

FIRST  LEFT  CEPHALO-ILIAC,  in  which  the  right  shoulder 
presents,  the  head  of  the  fetus  being  in  the  maternal  left  iliae  fossa, 
its  face  looking  posteriorly,  and  its  back  anteriorly.  This  is  likr\vi.M> 
called  the  first  dorso-anterior  position. 

SECOND  LEFT  CEPHALO-ILIAC,  in  which  the  left  shoulder 
presents,  the  head  of  the  fetus  being  in  the  maternal  left  iliac  fossa, 
its  face  looking  anteriorly,  and  its  back  posteriorly.  This  is  likewise 
called  the^r.s^  dor  so-posterior  position. 

FIRST  RIGHT  CEPHALO-ILIAC,  in  which  the  right  shoulder 
presents,  the  head  of  the  fetus  being  in  the  maternal  right  iliac  fossa, 
its  face  looking  anteriorly,  and  its  back  posteriorly.  This  is  likewise 
called  the  second  dorso-posterior  position. 

SECOND  RIGHT  CEPHALO-ILIAC,  in  which  the  left  shoulder 
presents,  the  head  of  the  fetus  being  in  the  maternal  right  iliac  fossa, 
its  face  looking  posteriorly,  and  its  back  anteriorly.  This  is  likewise 
called  the  second  dorso-anterior  position. 

The  PELVIC,  or  BREECH  PRESENTATION,  is  divided  into 
four  positions,  the  sacrum  of  the  fetus  being  the  diagnostic  guide.  In 
this  presentation,  the  delivery  is  generally  accomplished  by  the  natural 
powers,  without  the  intervention  of  art,  though  it  is  slow,  tedious,  and 
painful  to  the  mother,  and  more  dangerous  to  the  fetus  than  vertex, 
or  face  presentations;  the  mortality  to  the  child  is  owing  to  pressure 
of  the  os  uteri  on  its  body,  which,  by  forcing  the  blood  toward  its 
head,  produces  congestion  of  that  organ;  it  may  also  be  owing  to  the 
tardiness  of  the  labor,  and  the  compression  of  the  cord  during  the 
delivery  of  the  head.  Why  the  breech  should  present,  has  not  been 
satisfactorily  explained.  Breech  presentations  have  occurred,  accord- 
ing to  statistics,  2,438  times  in  129,117  cases,  or  about  1  in*52,  and  the 
mortality  to  the  child  is  recorded  at  195  deaths  in  678  cases,  or  about 
1  in  3j.  Those  breech  presentations  in  which  the  back  of  the  child  is 
directed  anteriorly,  and  which  are  more  commonly  encountered,  are 
termed  first  positions;  those  in  which  the  fetal  back  is  directed 
posteriorly,  are  termed  second  positions.  The  other  positions  which 
have  been  given  by  former  writers,  as,  sacro-pubic,  sacro-sacral,  etc., 
I  have  wholly  omitted,  as  I  doubt  very  much  whether  they  really 
occur ;  but  should  they  ever  be  presented  to  the  accoucheur,  he  will 
be  guided  in  their  management,  by  the  rules  hereafter  laid  down 
Knee  and  feet  presentations  are  mere  deviations  from  the  breech,  and 


PRESENTATIONS    AND    POSITIONS.  339 

are  even  more  tedious  and  dangerous  to  the  child  than  this,  on  account 
of  the  delay  in  the  delivery  of  the  head,  the  maternal  parts  not  being 
so  well  dilated,  as  when  the  breech  presents,  with  the  extremities 
flexed  upward.  Knee  presentations  are  rare,  occurring  about  once  in 
3,445  cases;  statistics  give  1,268  foot  and  knee  presentations  in '117,640 
cases,  or  about  1  in  92f,  and  the  mortality  to  the  child  is  recorded  at 
210  deaths  in  562  cases,  or  about  1  in  2J. 

POSITIONS  OF  BREECH    PRESENTATIONS. 

1st.  FIRST  LEFT  SACRO-ILIAC,  in  which  the  back  or  sacrum 
of  the  fetus  looks  anteriorly  and  to  the  left;  its  abdomen  posteriorly 
and  to  the  right;  its  transverse  or  bitrochanteric  diameter  occupying 
the  right  oblique  pelvic  diameter. 

2d.  FIRST  RIGHT  SACRO-ILIAC,  in  which  the  sacrum  of  the 
fetus  looks  anteriorly  and  to  the  right;  its  abdomen  posteriorly  and 
to  the  left ;  its  transverse  diameter  occupying  the  left  oblique  pelvic 
diameter. 

3d.  SECOND  LEFT  SACRO-ILIAC,  in  which  the  sacrum  of  the 
Ait  us  looks  posteriorly  and  to  the  left;  its  abdomen  anteriorly  and  to  the 
right;  its  transverse  diameter  occupying  the  left  oblique  pelvic  diameter.- 

4th.  SECOND  RIGHT  SACRO-ILIAC,  in  which  the  sacrum  of 
the  fetus  looks  posteriorly  and  to  the  right;  its  abdomen  anteriorly 
and  to  the  left;  its  transverse  diameter  occupying  the  right  oblique 
pelvic  diameter. 

In  KNEE  PRESENTATIONS,  the  feet  are  always  to  be  brought 
down,  and  the  positions  of  the  feet  (corresponding  with  those  of  the 
breech),  are  determined  by  the  heel;  thus,  first  left  calcaneo-iliac ,  or 
heels  to  the  left  and  front;  first  right  calcaneo-iliac,  or  heels  to  the 
right  and  front;  second  left  calcaneo-iliac,  or  heels  to  the  left  and 
posteriorly;  second  right  calcaneo-iliac,  or  heels  to  the  right  and 
posteriorly.  The  position  of  the  heels  enables  us  more  readily  to 
determine  the  position  of  the  breech. 

To  briefly  recapitulate,  the  presentations  and  positions  are  as  follows : 

Presentations.  Positions.         '         Presentations.  Positions. 


VERTEX. 


1.  Left  Occipito-anterior. 

2.  Right  Occipito-anterior.    gHOULDER.    . 


3. 

4.  Left  Occipito-posterior. 


1.  First  Left  Cephalo-iliae. 

2.  Second  Left  Cephalo-iliac. 

3.  First  Right  Cephalo-iliac. 

4.  Second  Right  Cephalo-iliac. 


5.  Right  Occipito-posterior.  f  j_  pirst  Left  Sacro-iliac. 

6.  Occipito-sacral.  »„„„,„          J   2.  First  Right  Sacro-iliac. 

It  Sacro-iliar. 
'lit  Sacro-iliac. 


.     ccpito-sacra.  j   2.  First  Right  Sacro-iliac. 

-r,.  _  f  1.  Left  Mento-iliac.  1   3.  Second  Left  Sacro-iliar. 

I  2.  Right  Mento-iliac.  t  4.  Second  Right  Sacro-ilia 


340  KI.Nc's    ECLECTIC   OBSTETRICS. 

.CHAPTER   XXVIII. 

MECHANISM    OF    LABOR. 

IT  has  been  heretofore  remarked,  that  presentation  of  the  vertex  is 
the  most  common  of  all  —  the  mechanism  of  which  includes  descent, 
liexion,  rotation,  restitution  aiid  expulsion  of  the  trunk;  and  among 
the  positions,  the  left  occipito-anterior,  or  that  in  which  the  occiput  is 
directed  toward  the  left  acetabulum,  is  more  frequently  met  with,  oc- 
durring,  according  to  statistics,  about  69  times  in  every  100  cases.  In 
.1,913  cases,  reported  by  M.  Dubois,  1,339  were  left  occipito-anterior, 
494  right  occipito-posterior,  55  right  occipito-anterior,  and  12  left  oc- 
cipito-posterior.  Why  the  occiput  is  found  so  much  more  frequently 
in  front  is  difficult  to  determine;  but  its  position  at  the  left  anterior 
of  the  pelvis  may  be  accounted  for  by  the  rectum  on  the  left  side, 
•which,  being  usually  distended  wyith  fecal  matters,  diminishes  the 
right  oblique  diameter,  so  that  the  head  being  forced  to  traverse  the 
most  ample  diameter,  the  occiput  is  thrown  to  the  left  acetabulum, 
and  the  forehead  to  the  right  sacro-iliac  symphysis. 

As  already  remarked,  vertex  presentations  are  always  more  favor- 
able for  both  mother  and  child,  than  any  other.  The  occipito-posterior 
positions  are,  however,  less  so  than  the  occipito-anterior,  in  conse- 
quence of  the  difficult  descent  of  the  head,  the  more  frequent  demands 
for  artificial  aid,  the  greater  liability  of  laceration,  or  perforation  of 
the  perineum,  and  from  the  delay  in  the  advance  of  the  head  often 
creating  sloughs,  and  urinary,  or  stercoral  fistulse. 

The  presence  of  a  vertex  presentation  may  frequently  be  recognized 
during  the  last  few  weeks  of  pregnancy,  even  before  the  finger  can  be 
introduced  within  the  os  uteri;  a  regular,  solid,  rounded  tumor  may 
be  felt  through  the  inferior  portion  of  the  uterine  parietes,  which  can 
be  raised  by  the  finger  with  more  or  less  difficulty  as  the  pregnancy  is 
more  or  less  advanced.  And  when,  at  the  commencement  of  labor, 
the  presenting  part  can  not  be  easily  reached,  or  the  round,  resisting 
surface  of  the  head  is  not  encountered,  .there  may  be  some  other  than 
a  vertex  presentation,  and  the  labor  should  be  closely  watched  during 
the  first  stage,  in  order  to  determine,  as  soon  as  possible,  the  nature 
of  the  presenting  part,  and  be  thereby  enabled  to  rectify,  at  the  proper 
period,  any  accidents  which  may  present  themselves.  Nseg^le  states, 
that  various  circumstances,  independent  of  malposition,  may  occur, 
which  will  prevent  the  presenting  part  from  being  felt  at  the  end 


MECHANISM    OF    LABOR.  341 

of  gestation;  as  in  cases  of  multipart,  where  the  uterine  fundus  is 
-strongly  inclined  forward;  in  twin  cases;  in  breech  presentations; 
where  a  large  quantity  of  amniotic  fluid  is  present ;  where  the  uterus 
is  not  oval  at  its  inferior  part;  when  there  is  a  hydrocephalous  head  ;  and 
where  the  pelvis  is  narrow.  As  soon  as  the  dilatation  of  the  os  uteri 
has  so  far  proceeded  as  to  admit  the  introduction  of  the  finger,  during 
the  absence  of  a  pain,  the  large,  rounded,  smooth  and  solid  surface 
of  the  head  can  be  felt  through  the  membranes,  and  if  the  dilatation 
be  sufficient,  membranous  spaces,  answering  to  the  sutures  and  fonta- 
nelles,  may  be  recognized;  and  if  the  head  be  pressed  upon,  a  resist- 
ance of  a  somewhat  elastic  character  may  be  noticed.  But  great  care 
is  necessary  to  prevent  these  examinations  from  prematurely  rupturing 
the  membranes.  After  the  membranes  have  ruptured,  at  the  close 
of  the  first  stage,  these  diagnostic  signs  are  more  manifest. 

After  having  correctly  ascertained 'the  presentation,  the  next  thing 
will  be  to  determine  the  position,  and  this  should  always  be  done  at 
as  early  a  period  as  possible,  in  order,  the  more  readily  to  remedy 
any  difficulties  which  may  occur.  The  diagnosis  can,  in  many 
instances,  be  effected  previous  to  the  rupture  of  the  membranes; 
but,  most  frequently,  it  will  be  impossible  to  arrive  at  it,  until  after 
this  has  occurred,  and  then,  it  should  always  be  accomplished  without 
<lelay. 

Auscultation  has  been  spoken  of,  as  affording  aid  in  determining 
the  position;  thus,  if  the  fetal  heart  is  heard  pulsating  in  the  left 
iliac  fossa,  the  occiput  is  to  the  left,  and  if  in  the  right,  it  is  to  the 
right,  etc. ;  but  there  is  too  much  uncertainty  in  this  mode  of 
diagnosticating,  to  admit  of  its  employment  in  actual  practice ;  the 
examination  per  vaginam  is  the  only  one  on  which  dependence 
must  be  placed.  The  same  may  be  said  in  relation  to  the  active 
motions  of  the  fetus,  whose  anterior  region  is  supposed  to  corre- 
spond with  the  point  of  the  uterus  at  which  these  have  been 
recognized  for  a  long  time.  The  practitioner  may  attend  to  these 
symptoms,  for  the  purpose  of  verifying  their  accuracy,  or  of  leading 
to  a  more  positive  determination  of  their  real  value ;  but  he  should 
not  allow  a  labor  to  proceed  solely  upon  the  indications  they  afford. 

In  order  to  arrive  at  the  position  of  a  vertex  presentation,  the 
accoucheur  should  render  himself  enabled  to  recognize  at  once,  the 
character  of  the  fontanelles  and  sutures,  a  description  of  which  has 
already  been  given,  and  the  exploring  finger  should  be  pressed  with 
sufficient  firmness  upon  the  head  to  enable  it  to  detect  them.  He 
must  also  bear  in  mind  that,  frequently,  while  the  head  is  descending, 


342 


KINGS    ECLECTIC    ORSTETKK  S. 


the  compression  it  undergoes,  is  such,  that  the  bones  are  forced  to 
overlap  each  other,  and  the  sutures,  instead  of  a  membranous  sensa- 
tion, convey  to  the  finger,  one  of  longitudinal  ridges  or  prominences ; 
and  the  distinctive  character  of  the  posterior  fontanelle  especially,  is 
lost,  being  recognized  merely  by  the  junction  of  the  sagittal  and 
lambdoidal  sutures,  or  rather  the  longitudinal  prominences  which 
they  present  from  the  pressure. 

IST.   LEFT  OCCIPITO-ANTEKIOR  POSITION. 

DIAGNOSIS. — In  this  position,  the  finger,  upon  being  introduced 
into  the  vagina,  or  within  .the  os  uteri,  will  first  come  in  contact  with 
the  boss  or  protuberance  of  the  right  parietal  bone  of  the  fetal  head, 
which  is  the  most  depending  part,  and  not  the  posterior  fontanelle,. 
which  latter  will  be  found  in  the  region  of,  and  corresponding  nearly 
to  the  maternal  left  acetabulum  ;  the  sagittal  suture  may  then  be 
FIG.  46  traced  running  from 

this  triangular  fon- 
tanelle, obliquely 
across  the  pelvis, 
from  below  upward, 
and  from  before 
backward,  and  from 
left  to  right,  until 
it  meets  with  the 
large,  soft,  mem- 
branous, and  quad- 
rangular anterior 
fontanelle,  w  h  i  c  h 
will  be  toward  the 
right  sacro-iliac 
symphysis.  The 
back  of  the  child 
will  be  toward  the 
front  and  left  of  the 
mother's  abdomen, 
while  its  abdomen 
will  be  toward  her 
back  and  right;  its 

right  shoulder  will  be  in  front  and  to  the  right,  and  its  left,  back  and 
to  the  left.  (Fig.  46.) 


MECHANISM    OF    LABOR.  -°,4.°> 

MECHANISM. — The  waters  having  been  discharged  by  the  rup- 
ture of  the  membranes,  the  expulsive  contractions  of  the  uterus  force 
the  head,  which  presents  obliquely  at  the  superior  strait,  down  into 
the  brim  of  the  pelvis,  its  flexion  upon  the  chest  is  increased,  so  that 
.the  neck  is  bent  more  into  a  curve,  and  the  body  of  the  fetus  is  more 
or  less  compressed  and  rolled,  as  it  were,  into  a  ball,  occupying  much 
less  space  than  before.  At  first,  the  two  fontanelles  are  nearly  on  a 
level,  but  as  labor  progresses,  and  the  head  advances,  one  of  them, 
more  commonly  the  posterior,  will  be  found  gradually  descending,  as- 
the  uterine  contractions  cause  the  vertex  to  sink.  The  flexion  causes 
a  change  in  the  relations  of  the  head.  Previous  to  the  rupture  of  the 
membranes,  and  the  flexion  of  the  head,  the  occipito-frontal  diameter 
of  the  fetal  head  was  parallel  to  the  left  oblique  diameter  of  the 
superior  strait,  and  the  biparietal  of  the  former  coincided  with  the 
right  oblique  of  the  latter ;  but  now,  while  the  position  of  the  latter 
diameters  remains  unaltered,  the  former  changes,  the  occipito-breg- 
matic  of  the  fetal  head  corresponding  to  the  left  oblique  diameter 
of  the  strait,  in  place  of  the  occipito-frontal.  The  axis  of  the 
pelvis,  which,  previous  to  the  rupture,  coincided  with  the  trachelo- 
bregmatic  diameter  of  the  head,  now  corresponds  very  nearly  with  it& 
occipito-mental.  If  the  student  will  compare  the  diameters  of  the 
fetal  head  with  those  of  the  maternal  pelvis,  he  will  ascertain  that  this 
movement  of  flexion,  brings  the  smallest  diameters  of  the  head  in  cor- 
respondence with  the  smallest  of  the  pelvis,  thus  placing  it  in  a  position 
highly  favorable  to  its  ready  expulsion. 

The  descent  of  the  head  is  due  to  the  continuation  of  the  uterine 
contractions,  which  force  it  through  the  strait,  into  the  pelvic  cavity,, 
and  onward  to  the  lower  strait  of  the  pelvis.  In  its  passage  through 
the  pelvic  excavation,  it  undergoes  great  compression,  the  bones  over- 
lap each  other,  as  above  stated,  forming  longitudinal  ridges  along  the 
sutures,  and  sometimes,  when  the  pressure  is  very  considerable,  a 
tumor  is  formed  upon  the  scalp,  called  the  CAPUT  SUCCEDANEUM. 
The  obliquity  of  the  head  at  the  superior  strait  is  preserved  throughout 
its  descent,  with  the  exception  that  one  fontanelle  (the  posterior)  is,, 
more  commonly,  lower  than  the  other.  The  contractions  urge  the 
head  downward,  the  occiput  descends  on  the  left  antero-lateral  inclined 
plane,  while  the  forehead  moves  in  the  direction  of  the  right  sacro-iliae 
ftymphysis,  and  the  descent  is  wholly  perfected,  when  the  occipito- 
bregmatic  circumference  coincides  with  the  plane  of  the  inferior 
strait,  or  when  the  two  protuberances  of  the  parietal  bones  have 
arrived  at  this  level,  and  to  attain  which,  the  left  protuberance,  which 


344 


KINOES    ECLECTIC    OBSTETRICS. 


is  behind,  must  traverse  the  whole  anterior  face  of  the  sacrum, 
describing  the  arc  of  a  large  circle,  while  the  right,  which  is  anterior, 
traverses  a  shorter  distance,  describing  the  arc  of  a  much  smaller 
circle. 

When  the  head  arrives  at  the  floor  of  the  pelvis,  its  further  progress. 

is  arrested  by  the  perineum,  sacro-sciatic  ligaments,  etc.,  etc.,  which 

FIG.  47.  form  this  part;   but 

the  continuation  of 
the  uterine  contrac- 
tions effects  a  move- 
ment of  rotation 
from  left  to  right, 
in  which  the  occiput 
is  passed  behind  the 
symphysis  pubis,  a 
little  to  its  left, 
while  the  forehead 
rotates  into  the  hol- 
low of  the  sacrum, 
remaining,  however, 
a  little  to  the  right. 
(Fig.  47.)  In  this 
situation  the  occip- 
ito-mental  diameter 
of  the  head  is  al- 
most parallel  with 
the  axis  of  the  in- 
ferior strait,  and 
the  sagittal  suture 

nearly  coincides  with  the  antero-posterior  diameter  of  this  strait.  As 
the  resistance  at  the  floor  of  the  pelvis  is  gradually  overcome,  the 
occiput  continues  to  descend,  passing  under  the  arch  of  the  pubis 
until  the  neck  comes  in  contact  with  it,  when  its  further  advance  is 
arrested.  At  the  period  when  the  occiput  is  engaged  at  the  pu- 
bic arch,  the  shoulders  and  upper  part  of  the  body  engage  in  the 
superior  strait  with  their  long  diameters  in  the  same  direction  as 
was  taken  by  the  biparietal  diameter  of  the  head,  viz.:  its  right 
oblique  diameter. 

The  neck  being  immovably  fixed  against  the  pubis,  the  contractile 
efforts  being  always  in  a  line  with  the  axis  of  the  superior  strait,  are 
directed  upon  the  chin,  or  that  portion  of  the  head  which  lies  in  the 


MECHANISM    OF    LABOR. 


rvr 


Concavity  of  the  sacrum ;  the  chin  gradually  departs  from  the    chest, 
while    the    occiput    ascends,   forming    the  FIG.  48. 

motion  of  extension.  (Fiy.  48.)  During 
this  extension,  with  the  neck  fixed  against 
the  symphysis  pubis  as  a  pivot  for  the  head 
to  turn  upon,  the  forehead  and  face  pass 
over  the  curves  of  the  sacrum,  coccyx,  and 
perineum,  and  as  the  head  emerges,  the 
vulva  becomes  distended,  the  labia  majora 
are  effaced,  the  nymphse  are  pressed  up, 
the  perineum  becomes  thin,  yielding,  and 
distended,  and  the  sagittal  suture,  ante- 
rior fontanelle,  forehead,  nose,  mouth, 
and  chin,  appear  in  succession  at  the 
vulva,  and  the  head  is  born.  It  must  be 
remarked  here,  that  although  the  fetal  head  is  impelled  toward  the 
outlet  during  each  pain,  yet  each  remission  is  followed  by  a  recession 
of  the  head;  and  this  may  frequently  be  observed  when  the  occiput, 
which  has  appeared  at  the  vulva  during  a  pain,  recedes  within  the 
cavity  during  its  cessation,  having  the  labia  closed  over  it.  This 
recession  is  of  immense  benefit  to  the  woman,  as  the  distension  of  the 
parts  is  thereby  relieved.  Were  the  head  to  be  forced  onward  without 
any  such  relief,  the  circulation  in  the  parts  would  be  obstructed,  the 
vessels  would  be  more  or  less  strangulated,  and  inflammation,  fol- 
lowed by  gangrene,  would  be  very  apt  to  ensue.  From  a  similar 
cause,  it  is  likewise  advantageous  to  the  fetus,  an  undue  and  con- 
stant pressure  upon  the  head  of  which,  would  be  likely  to  cause 
its  death. 

The  passage  of  the  fetal  head  through  the  pelvic  cavity  is  often 
accompanied  with  cramps  in  the  inferior  extremities,  which  do  not, 
however,  interfere  with  the  action  of  the  uterus  or  the  progress  of  the 
labor,  but  are  sometimes  so  agonizingly  painful  as  to  demand  a  hasten- 
ing of  the  delivery  with  the  forceps :  the  cramps  are  owing  to  the 
compression  of  the  internal  sacral  nerves  by  the  head. 

A  few  seconds  after  the  delivery  of  the  head,  it  undergoes  another 
motion,  called  restitution,  in  which  it  becomes  directed  as  it  was  pre- 
vious to  rotation,  that  is,  with  the  face  looking  toward  the  internal 
posterior  surface  of  the  right  thigh  of  the  mother,  and  the  occiput 
toward  her  left  groin.  (Fig.  49.)  From  a  supposition  that  the  rota- 
tion was  effected  without  any  participation  of  the  body  therein,  merely 
occasioning  a  twisting  of  the  neck,  and  that  after  the  birth  of  the 


346 


KING'S    ECLECTIC    OBSTETRICS. 


head,  the  neck  untwisted,  restoring  the  head  to  its  natural  relation* 


FIG.  49. 


with  the  body,  the 
term  restitution  was 
applied  to  this  last 
motion.  But,  accord- 
ing to  Gerdy,  this  view 
ig  erroneous,  for  the 
trunk  does  rotate  with 
the  head  in  such  a 
manner  as  to  bring  the 
long  diameter  of  the 
shoulders,  which  was 
at  first  in  the  direction 
of  the  right  oblique 
diameter,  to  nearly 
correspond  with  the 
transverse  diameter  of 
the  pelvic  cavity.  They 
descend  and  reach  the 

floor  of  the  pelvis  in  this  transverse  position,  which  presents  their 
bis-acromial  diameter  to  the  small,  or  bis-ischiatic  diameter  of  the 
inferior  strait,  rendering  it  almost,  if  not  quite  impossible  for  them  to 
be  delivered.  Consequently,  the  resistance  offered  to  their  further 
advancement,  at  this  point,  by  the  uterine  contractions,  as  was  the  case 
with  the  head,  establishes  a  rotation,  which  causes  the  right  shoulder 
to  pass  from  the  right  side  toward  the  pubic  arch,  while  the  left  passes 
into  the  concavity  of  the  sacrum,  and  the  bis-acromial  becomes  nearly 
coincident  with  the  antero-posterior  diameter  of  the  inferior  strait,  and 
it  is  this  rotation  of  the  shoulders  which  causes  the  motion  of  the  head 
called  restitution;  it  necessarily  following  the  impulse  impressed  on 
the  shoulders. 

Sometimes,  however,  the  head  executes  a  motion,  a  short  time  pre- 
vious to  its  restitution,  and  which  occurs  immediately  after  its  expulsion. 
This  appears  to  be  owing  to  a  slightly  oblique  position  of  the  shoulders, 
while  the  occiput  is  about  passing  under  the  pubes  in  an  antero- 
posterior  direction,  which  imparts  a  slight  twist  to  the  child's  neck, 
and  from  which  it  is  relieved,  as  soon  as  the  head  is  delivered,  and 
free  from  the  soft  parts. 

Shortly  after  the  expulsion  of  the  head,  the  shoulders  having 
executed  the  motions  above  named,  the  right  shoulder  appears  at  the 
vulva  and  is  fixed  against  the  pubes,  while  the  posterior  or  left  shoulder 


MECHANISM    OF    LABOR. 


347 


traverses  the  perineal  cavity  in  the  same  manner  as  the  face  in  the 
delivery  of  the  head,  and  after  its  disengagement  at  the  anterior 
commissure  of  the  perineum,  the  right  or  sub-pubic  shoulder  follows. 
During  the  birth  of  the  shoulders,  the  trunk  of  the  child  becomes 
curved  laterally,  so  as  to  correspond  with  the  curvature  of  the  pelvic 
excavation ;  the  concavity  being  on  its  right  side,  and  the  convexity 
on  its  left. 

Frequently,  the  right  shoulder  will  be  the  first  delivered;  or  both 
shoulders  may  emerge  from  the  vulva  at  the  same  time.  After  the 
delivery  of  the  shoulders,  the  remainder  of  the  body  is  easily  expelled, 
describing  in  its  passage,  a  more  or  less  marked  spiral  movement. 

Thus,  then,  in  a  natural  labor,  with  an-  occipito-anterior  position, 
we  have  the  head  to  offer  its  smallest  diameters  and  circumference  to 
those  of  the  pelvis,  and  to  perform  the  motions  of  flexion,  descent, 
rotation,  extension  and  restitution.  (Fig.  50.) 


FIG.  50. 


KINGS    ECLECTIC    oliSTETUlcs. 


•_'n.     RIGHT  OCCIPITO-ANTERIOR  POSITION. 

DIAGNOSIS. — In  this  position,  the  finger  will  first  come  in  con- 
tact with  the  left  parietal  protuberance,  which  is  the  most  depending 
part,  and  the  posterior  fontanellc  will  be  found  corresponding  nearly 
.to  the  right  aeetabulum;  from  this  fontanelle  may  be  traced  the  sagit- 
o.  51.  tal  suture,  running  ob- 

liquely across  the  pelvis 
from  below  upward,  and 
from  before  backward, 
and  from  right  to  left, 
until  it  meets  the  ante- 
rior fontanelle,  which 
will  be  toward  the  left 
sacra  -  iliac  symphy.Ms. 
The  back  of  the  child 
will  be  toward  the  front 
and  right  of  the  moth- 
er's abdomen,  while  its 
abdomen  will  be  toward 
her  back  and  left;  its 
left  shoulder  will  be  in 
front  and  to  the  left, 
and  its  right,  back  and 
to  the  right.  (Fly.  51.) 
Madam  Boivin  re- 
cords 3,682  instances  of 
this  position  in  20, -317 
cases,  or  about  1  in  5-f  cases.  Nsege'le  states  that  though  more  ca.-e.-- 
are  terminated  in  this  position,  yet  that  its  frequency  as  an  original 
one  is  .07  per  cent.  Between  this  and  the  previous  position  there 
will  be  found  but  little  difference  in  practice.  Dewees  states  that  on 
account  of  the  right  lateral  obliquity  of  the  uterus  prevailing  so  often, 
and  the  rectum  being  occasionally  impacted  with  hardened  feces,  this 
position  is  less  favorable  than  the  first;  but,  he  adds,  we  may  control 
the  obliquity  by  placing  the  woman  upon  her  left  side,  and  can  empty 
the  rectum  by  an  injection. 

MECHANISM. — In  the  right  occipito-anterior  position  the  occip- 
ito-frontal  diameter  of  the  fetal  head  is  parallel  to  the  right  oblique 
diameter  of  the  superior  strait,  and  the  biparietal  of  the  former  coin- 


MKCHAXISM    OF    LABOR.  349 

cides  with  the  left  oblique  of  the  latter;  but,  as  in  the  first  position, 
when  the  membranes  rupture  and  the  head  descends,  the  occipito- 
bregmatie  diameter  of  the  head  takes  the  place  of  the  occipito-frontal, 
the  biparietal  remaining  unaltered.  The  flexion,  descent,  rotation, 
extension  and  restitution  are  the  same  as  in  the  previous  position, 
\vith  the  exception  that  rotation  takes  place  from  right  to  left,  and 
restitution  directs  the  face  toward  the  internal  posterior  surface  of 
the  left  maternal  thigh,  and  the  occiput  toward  the  right  groin.  The 
delivery  of  the  shoulders  is  likewise  the  counterpart  of  the  first 
position. 

3c.     OCCIP1TO-PUBAL  POSITION. 

DIAGNOSIS. — In  this  position  the  occiput,  or  posterior  fontanelle, 
will  be  detected  behind  the  symphysis  pubis,  and  the  sagittal  suture 
may  be  traced  [running  parallel,  or  nearly  so,  to  the  antero-posterior 
diameter  of  the  pelvis],  from  before  backward  and  upward,  until  it 
meets  the  anterior  fontanelle,  which  will  be  toward  the  sacrum.  The 
back  of  the  child  will  face  the  mother's  abdomen,  while  its  abdomen 
will  be  toward  her  back ;  its  right  shoulder  will  be  toward  her  right 
side,  and  its  left  toward  her  left. 

This  position  occurs  but  very  rarely,  though  Nsegele  considers  it  to 
be  the  original  one  in  all  occipi to-anterior  positions,  these  being 
merely  secondary  transformations  of  it,  and  recognized  only  because 
the  examination  is  made  at  too  advanced  a  period.  Baudelocque  met 
with  it  twice  in  10,329  cases;  Madam  Boivin  6  times  in  20,517;  and 
Madam  La  Chapelle  not  once  in  30,000. 

MECHANISM.  —  In  the  occipito-pubal  position,  the  occipito- 
bregmatic  diameter  of  the  fetal  head  corresponds  with  the  antero- 
posterior  pelvic  diameter,  and  its  biparietal  with  the  pelvic  trans- 
verse. The  mechanism,  when  the  head  is  small,  as  compared  with 
the  pelvis,  differs  from  the  two  preceding  positions,  in  the  head 
executing  only  the  motions  of  flexion,  descent  and  extension;  as  rota- 
tion is  unnecessary,  and  the  direction  of  restitution  will  depend 
entirely  upon  which  shoulder  engages  at  the  pubic  arch,  as  rotation 
of  the  shoulders  must  ensue  before  they  can  be  delivered.  The  labor, 
if  not  interfered  with  by  any  uterine  obliquity  which  will  remove  the 
head  from  the  center  of  the  pelvis,  will  be  as  favorable  as  in  either  of 
the  preceding  cases. 

Labor  may  be  facilitated,  when  the  head  is  in  this  position,  making 
but  little  advance,  by  changing  it  to  one  of  the  occipito-anterior 


350 


KINti's    ECLECTIC    OBSTETRICS. 


positions,  especially  when  the  vertex  is  high  up,  and  manifests  no  dis- 
position to  assume  one  of  these  positions  after  the  occurrence  of  three 
or  four  pains.  To  effect  this  change,  the  head  may  be  grasped  be- 
tween the  thumb  and  fingers,  and  the  face  inclined  laterally;  but  the 
operation  must  not  be  attempted  until  the  os  uteri  is  well  dilated,  the 
soft  parts  yielding,  and  the  head  at  the  superior  strait,  not  impacted, 
but  free  and  movable,  and  during  the  absence  of  pain.  If  the  change 
can  not  be  effected,  we  must  then  wait  until  symptoms  present  them- 
selves indicating  the  necessity  of  interference  by  forceps  or  otherwise. 
Indeed,  when  the  head  is  large,  unless  it  be  changed,  either  naturally 
or  artificially,  to  an  occipito-anterior  position,  there  will  be  but  little 
progress  in  the  labor. 

4Tii.    LEFT  OCCIPITO-POSTERIOR  POSITION. 

DIAGNOSIS. — In  this  position  the  occiput  is  placed  at  the  left 

sacro-iliac  symphysis,  and  the  forehead  at  the  right  acetabulum.  The 

anterior  fontanelle  will 
be  found  behind  the 
right  acetabulum,  from 
which  the  sagittal  suture 
may  be  traced  running 
obliquely  across  the  pel- 
vis, from  before  back- 
ward, and  from  above 
downward,  and  from 
right  to  left,  until  it 
meets  with  the  posterior 
fontanelle,  which  will  be 
toward  the  left  sacro- 
iliac  symphysis.  The 
right  parietal  protuber- 
ance is  the  lowest  in  the 
pelvis,  and  the  finger 
will  come  in  contact 
with  it  the  first.  The 
back  of  the  child  will 
be  toward  the  back  of 
the  mother  and  to  the 

left,  while  its  abdomen  will  be  toward  her  abdomen,  and  to  the  right; 

its  right  shoulder  will  be  toward  her  abdomen  and  to  the  left,  and  its 

left  to  her  back  and  right.     (Fly.  52.) 


MECHANISM    OF    LABOR.  351 

This  position  is  very  rare,  occurring,  according  to  Noegele,  in  the 
ratio  of  .03  per  cent.;  to  La  Chapelle  of  .04  per  cent.;  and  to  Boivin 
of. 05  percent.  It  is  more  unfavorable  than  the  right  occipito-pos- 
terior  position,  the  labor  being  more  painful  and  protracted;  this 
arises  from  causes  similar  to  those  named  under  the  second  position, 
and  may  be  remedied,  to  a  certain  extent,  by  the  same  means  as 
therein  mentioned. 

MECHANISM. — If  the  examination  per  vaginam  be  made  at  an 
early  period,  before  the  head  has  undergone  much  flexion,  the  oc- 
cipito-frontal  diameter  will  be  found  to  coincide  with  the  right 
oblique  pelvic  diameter,  and  the  biparietal  with  the  left  oblique. 
With  the  descent  of  the  head,  the  same  as  in  the  previous  positions, 
flexion  takes  place,  which  changes  the  situation  of  the  head  so  as  to 
bring  the  occipito-bregmatic  diameter  in  correspondence  with  the 
right  oblique  diameter  of  the  pelvis;  and  the  occipito-mental  diam- 
eter of  the  head  runs  nearly  parallel  with  the  axis  of  the  superior 
strait.  At  first  the  anterior  fontanelle  will  be  found  in  the  center  of 
the  pelvis,  but  as  the  head  becomes  flexed  and  descends  it  rises,  while 
the  posterior  fontanelle,  previously  beyond  the  touch,  descends,  and 
engages  in  the  pelvic  cavity.  The  descent  occurs  in  the  same  manner 
as  already  described  in  the  preceding  instances.  When  the  head  has 
reached  the  floor  of  the  pelvis,  rotation,  which  is  much  more  extended 
than  in  the  occipito-anterior  positions,  takes  place,  the  occiput  de- 
scribes an  arc  from  left  to  right,  and  is  carried  round  to  the  symphy- 
sis  pubis,  through  the  left  side  of  the  pelvis,  when  the  head  is  deliv- 
ered in  the  same  manner  as  if  it  had  been  an  original  anterior  position : 
the  first.  This  extensive  rotation  could  not  be  effected  with  safety 
to  the  child  unless  the  body  participated  in  the  motion,  and  which 
must,  of  course,  require  a  long  time  to  accomplish ;  but  wThen  com- 
pleted the  labor  proceeds  favorably,  the  right  shoulder  is  soon,  brought 
under  the  pubic  arch,  and  the  left  passed  into  the  sacral  concavity, 
and  the  delivery  is  terminated  as  usual.  The  movement  of  restitu- 
tion places  the  face  of  the  child  toward  the  internal  part  of  the  right 
maternal  thigh,  and  its  occiput  toward  the  internal  part  of  the, left 
thigh.  It  is  often  the  case  in  this  position,  and  especially  in  primip- 
arous  women,  that,  nature  becoming  exhausted,  artificial  assistance  is 
demanded. 

The  above  method  is  the  one  in  which  delivery  is  most  commonly 
effected  in  the  posterior  occipital  positions,  but  occasionally  it  occurs 
in  another  ^way.  WThen  the  head  arrives  at  the  floor  of  the  pelvis, 


352 


KINGS    ECLECTIC    OBSTETRICS. 


the  rotation  places  the  forehead  under  the  symphysis  pubis,  and  the 
occiput  in  the  hollow  of  the  sacrum.  (Fig.  53.)  In  this  position  the 
face  of  the  child  will  be  to  the  front  of  its  mother,  and  its  back  to 
her  sacrum;  the  occipito-frontal  diameter  of  its  head  will  coincide 
with  the  pelvic  antero-posterior,  and  the  biparietal  will  be  transverse, 
as  well  as  the  bis-acromial. 

In  this  position,  the  uterine  contractions  still  further  increase  the 
flexion  of  the  head,  the  occiput  is  forced  to  gradually  traverse  the 
FIG.  53.  sacral,  coccygeal,  and  peri- 

neal  curve,  the  perineum 
becomes  greatly  distended 
and  elongated,  the  occiput 
passes  over  the  posterior 
commissure,  and  the  head 
passes  out  by  its  occipito- 
frontal  diameter.  As  the 
occiput  is  passing  outward, 
the  forehead  rises  behind 
the  symphysis  pubis,  thus 
giving  more  space  for  the 
head  to  pass  through.  Some- 
times, after  the  delivery  of 
the  occiput,  the  neck  be- 
comes fixed  against  the  per- 
ineum, and  the  forehead, 
face,  and  chin  of  the  child, 
successively,  emerge  from  under  the  pubic  arch.  Should  the  fore- 
head descend  so  low  that  the  eyebrows  may  be  felt,  it  will,  by  pre- 
senting an  impediment  to  its  elevation  behind  the  pubic  symphysis 
at  the  time  of  the  passage  of  the  occiput  over  the  perineal  curve,  very 
much  increase  the  difficulty  of  the  labor. 

Dr.  Dewees  states,  "\Ve  almost  always  have  it  in  our  power  to 
reduce  this  and  the  fifth  "  (when  they  occur  with  the  occiput  in  the 
hollow  of  the  sacrum,  as  just  described),  "one  to  the  second,  and  the 
other  to  the  first,  and  we  should  always  do  so  when  nature  does  not 
do  it  for  us.  Nor  is  this  change  of  position  of  the  head  an  operation 
of  the  slightest  difficulty  to  the  accoucheur;  neither  does  it  cause  the 
smallest  pain  to  the  patient,  provided  advantage  be  taken  of  the 
proper  conditions  of  the  uterus,  and  head  of  the  child,  and  state  of  the 
labor.  For  the  uterus  must  be  well  dilated,  the  membranes  ruptured, 


MECHANISM    OF    LABOR.  353 

the  head  occupying  the  lower  strait,  and  the'  labor  active.  When 
these  prerequisites  obtain,  the  point  of  the  forefinger  must  be  placed 
against  the  edge  of  the  sagittal  suture  either  before  or  behind  the  an- 
terior fontanelle,  and,  in  the  absence  of  pain,  this  part  must  be  pressed 
toward  the  left  sacro-iliac  symphysis,*  and  maintained  there  during 
the  subsequent  contraction  of  the  uterus.  Should  this  attempt  fail  in 
changing  the  position  of  the  head,  by  bringing  the  posterior  font- 
anelle to  the  right  acetabulum,  the  attempt  must  be  repeated  again 
and  again  until  it  succeeds,  which  it  will  almost  constantly  do." 

The  expulsion  of  the  head  in  the  occipital  posterior  positions  may, 
in  consequence  of  a  premature  extension,  fix  the  occiput  in  the  hollow 
of  the  sacrum,  and  thus  the  face  be  forced  downward  by  the  contrac- 
tions, delivery  occurring  as  in  face  presentations;  but,  in  order  to 
effect  such  a  change  in  the  pelvic  cavity,  the  natural  size  of  the  head 
must  be  considerably  reduced,  or  the  diameters  of  the  excavation 
must  be  very  large. 

In  all  the  occipito-posterior  positions  there  may  be  a  failure  of 
complete  rotation,  a  want  of  energy  of  uterine  contraction,  or  exhaust- 
ion, etc.,  either  of  which  will  require  the  interference  of  art. 

« 
STH.     RIGHT  OCCIPITO-POSTERIOR  POSITION. 

DIAGNOSIS. — In  this  position  the  occiput  is  placed  at  the  right 
sacro-iliac  symphysis,  and  the  forehead  at  the  left  acetabulum,  the 
anterior  fontanelle  will  be  found  behind  the  left  acetabulum,  from 
which  the  sagittal  suture  may  be  traced  running  obliquely  across  the 
pelvis,  from  in  front  backward,  and  from  above  downward,  and  from 
left  to  right,  until  it  meets  with  the  posterior  fontanelle,  which  will 
be  toward  the  right  sacro  iliac  symphysis.  The  left  parietal  protu- 
berance is  the  most  depending  part,  and  with  which  the  finger  will 
first  come  in  contact.  The  back  of  the  child  will  be  toward  the  back 
of  the  mother  and  to  the  right,  while  its  abdomen  will  be  toward  her 
abdomen,  and  to  the  left;  its  right  shoulder  will  be  toward  her  back 
and  to  the  left,  and  its  left  to  her  abdomen  and  right.  (Fig.  54.) 

This  is  considered  the  most  common  of  the  occipito-posterior  posi- 
tions, and  is  stated  by  Nsegele  to  be  the  next  in  frequency,  among  the 

*In  the  fourth  position  of  the  vertex,  while  attempting  the  above  reduction,  the  fore- 
head must  be  pushed  toward  the  right  sacro-iliac  symphysis,  which  will  reduce  it  to  the 
first  position;  in  the  fifth  position,  the  pressure  must  be  made  in  the  direction  toward 
the  left  sacro-iliac  symphysis,  which  will  place  the  head  in  the  second  position. — Author. 

23 


354 


KING'S    ECLECTIC    OBSTETRICS. 


FIG.  54. 


vertex  presentations,  to  the  left  occipito-anterior,  occurring  in  the 
ratio  of  29  per  cent.  In  355  cases,  related  by  Simpson,  256  were 
in  the  first  position,  1  in  the  second,  2  in  the  fourth,  and  76  in 
the  fifth.  Its  frequency  is  supposed  to  be  owing  to  the  same  cause 

which  gives  rise  to  the 
left  occipito-anterior 
position,  viz.:  the  press- 
ure of  the  rectum  on 
the  left  side  of  the  pel- 
vis, which  happens 
especially  when,  as  is 
common  to  women  ad- 
vanced in  pregnancy, 
there  is  an  accumulation 
of  hardened  feces.  It 
is  a  more  unfavorable 
position  than  the  first 
three,  and  the  labor, 
though  generally  ac- 
complished by  the  nat- 
ural powers,  is  more 
tedious  and  painful  than 
with  the  occipito-ante- 
rior positions. 

MECHANISM.- 
This  is  the  counterpart 
of  the  fourth  position,  and  difficulties  or  changes  may  be  encountered, 
similar  to  those  met  with  in  that  position.  At  the  commencement  of 
labor,  the  occipito-frontal  diameter  will  be  found  to  coincide  with  the 
left  oblique  pelvic  diameter,  and  the  biparietal  with  the  right  oblique; 
the  two  foutanelles,  as  in  the  preceding  case,  being  at  nearly  the  same 
level.  As  the  labor  advances,  flexion  ensues,  and  the  occipito-breg- 
matic  diameter  takes  the  place  of  the  occipito-frontal,  the  axis  of  the 
superior  strait  corresponding  nearly  with  the  occipito-mental  diam- 
eter. Flexion,  descent,  extensive  rotation  and  restitution,  occur  as  in 
the  preceding  case,  with  the  exception  that  the  rotation  takes  place 
from  right  to  left,  the  occiput  sweeping  around  the  right  side  of  the 
pelvis,  the  left  shoulder  is  brought  to  the  pubic  arch,  and  restitu- 
tion brings  the  face  of  the  child  toward  the  internal  part  of  the  left 
maternal  thigh,  and  its  occiput  toward  the  internal  part  of  the  right 


MECHANISM    OF    LABOR. 
FIG.  55. 


355 


thigh — or,  as  in  the  preceding  position,  rotation  may  place  the  fore- 
head under  the  pubic  arch,  and  the  occiput  in  the  hollow  of  the  sac- 
rum, as  shown  in  Fig.  55. 


BTH.     OCCIPITO-SACKAL  POSITION. 

DIAGNOSIS. — In  this  position  the  forehead  or  anterior  fontanelle 
will  be  detected  behind  the  symphysis  pubis,  and  the  sagittal  suture 
may  be  traced  [running  parallel  or  nearly  so,  to  the  antero-posterior 
diameter  of  the  pelvis],  from  before,  backward,  and  downward,  until 
it  meets  the  posterior  fontanelle  or  occiput,  which  will  be  toward  the 
sacrum.  The  back  of  the  child  will  face  the  mother's  back,  while  its 
abdomen  will  be  toward  her  abdomen ;  its  right  shoulder  will  be 
toward  her  left  side,  and  its  left  toward  her  right. 

This  position  is  of  very  rare  occurrence,  so  much  so  that  its  exist- 
-ence  is  doubted  by  some  accoucheurs,  and,  together  with  the  third,  it 
is  not  classified  as  a  position  by  several  authors.  In  20,517  deliveries 
it  was  met  with  but  twice. — Boivin. 

MECHANISM. — In  the  occipito-sacral  position,  the  occipito-breg- 
matic  diameter  of  the  fetal  head  corresponds  with  the  antero-posterior 
.pelvic  diameter,  and  its  biparietal  with  the  pelvic  transverse.  The 
mechanism  differs  from  the  two  preceding  positions,  in  the  head  exe- 
cuting only  the  motions  of  flexion,  descent,  increased  flexion  and 


356  KINfi's    ECLECTIC    OBSTETRICS. 

extension.  The  motion  of  rotation' is  unnecessary,  and  the  direction- 
of  restitution  will  depend  upon  which  shoulder  engages  at  the  pubic 
arch.  If  nature  does  not  reduce  this  to  an  occipito-posterior  position. 
and  the  labor  is  slow  and  painful,  it  may  be  facilitated  by  effecting  the 
reduction  artificially,  in  the  same  manner,  and  guided  by  the  same 
rules,  as  named,  when  treating  of  the  mechanism  of  occipito-pubal 
positions.  The  head  may  present  in  positions  not  exactly  agreeing 
with  those  just  given,  relative  to  which,  Dr.  Dewees  very  correctly 
remarks :  "  Mathematical  precision  is  not  required  in  such  cases, 
especially  as  the  mechanism  of  the  labor  is  not  altered  ;  for  when  the 
posterior  fontanelle  is  at  all  in  advance  of  the  sacro-iliac  junction, 
either  right  or  left,  it  will  almost  always  eventually  place  itself  under 
the  arch  of  the  pubes,  and  this  is  all  that  is  necessary." 

In  may  be  proper  to  remark  here  that  sometimes  the  movements  of 
the  head  do  not  occur  exactly  in  the  manner  just  described.  Flexion, 
for  instance,  will  be  found  to  occur  previous  to  the  descent  of  the 
head,  or  simultaneously  with  it,  or  not  until  the  head  has  reached  the 
pelvic  floor ;  and,  occasionally,  extension  will  take  place  so  far  as  to 
gradually  place  the  anterior  fontanelle  in  the  center  of  the  pelvic 
cavity,  flexion  occurring,  however,  as  soon  as  the  descent  is  completed  ; 
this  last  irregularity  is  more  usual  with  the  occipito-posterior  positions. 
Again,  Dubois  has  met  with  a  few  cases,  in  which  excessive  flexion 
brought  the  posterior  fontanelle  to  the  center  of  the  excavation  (or 
perhaps,  an  inclination  of  the  trunk  backward,  may  have  effected  it), 
but  which  was  restored  to  its  proper  situation  upon  meeting  with  the 
resistance  from  the  pelvic  floor. 

Rotation  may  also  vary ;  it  may  commence  while  the  head  is  at  the 
upper  part  of  the  pelvic  cavity,  so  that  flexion,  descent,  and  rotation 
occur  simultaneously;  or  it  may  not  take  place  until  the  head  has 
almost  passed  the  posterior  commissure  of  the  vulva.  Rotation  may 
also  be  incomplete,  or  it  may  be  so  extensive  as  to  carry  the  occiput, 
not  only  to  the  pubic  symphysis,  but  even  beyond  it,  to  the  acetabulurn 
of  the  opposite  side ;  in  these  latter  instances,  after  a  short  period  of 
rest,  it  again  places  itself  behind  the  symphysis,  by  a  retrograde 
motion.  These  irregularities  are  not  easily  accounted  for,  and  though 
they  may  render  the  delivery  tedious,  yet  it  will  generally  be  effected 
without  any  artificial  interference. 

Rotation  of  the  shoulders  likewise,  offers  some  irregularities;  it  may 
be  wanting,  or  it  may  be  incomplete,  or  it  may  be  excessive,  the  sama 
as  with  the  rotation  of  the  head. 


MECHANISM    OF    LABOR.  357 

The  pressure  upon  the  circumference  of  the  head,  produces  a  sero- 
sanguineous  engorgement  over  the  part  not  subjected  to  the  compres- 
sion, and  which  is  always  the  lowest  or  presenting  part.  This  tumor, 
caput  succedaneum,  may  become  so  developed  as  to  obscure  the 
diagnosis,  or  lead  to  the  supposition  of  a  breech  presentation ;  but,  if 
the  finger  be  carried  beyond  its  circumference,  the  bony  resistance  of 
the  head  will  determine  the  presentation.  The  diagnosis  of  the  posi- 
tion, may,  however,  not  be  so  readily  ascertained,  as  this  engorged 
condition  of  the  scalp  may  prevent  the  detection  of  the  fontanelles  ;  in 
such  cases,  the  delivery  will  require  to  be  performed  without  inter- 
ference, bearing  in  mind,  that  in  vertex  presentations,  the  major  part 
are  delivered  by  the  unaided  efforts  of  nature. 

This  tumor  of  the  scalp  is  an  unerring  indicator  of  the  •  position 
of  the  fetal  head ;  thus,  in  the  left  occipito-anterior  position,  it  will 
be  found  on  the  right  parietal  protuberance,  and  in  the  right 
occipito-anterior  on  the  left;  in  the  occipito-posterior  positions,  it 
is  located  about  the  center  of  the  vertex,  sometimes  on  the  anterior 
fontanelle,  but,  generally,  to  correspond  with  the  part  originally  at 
the  os  uteri,  and  subsequently  with  the  part  which  presents  under  the 
pubic  arch. 

It  may  be  distinguished  from  a  sanguineous  tumor  of  the  head, 
which  Nsege'le  has  termed  cephalcematoma,  by  the  following  charac- 
teristics :  it  is  irregularly  circumscribed,  being  larger  in  proportion 
to  the  tediousness  of  the  labor ;  is  always  single ;  is  oedematous, 
retaining  the  pit  of  the  finger ;  has  no  fluctuation ;  and  the  scalp  is 
of  a  well-marked  violet  color.  The  cephalsematoma  vary  in  size,  from 
a  small  nut  to  a  hen's  egg ;  it  is  distinctly  circumscribed ;  possesses 
a  well-marked  fluctuation,  sometimes  pulsations ;  its  center  is  some- 
times so  greatly  depressed  as  to  be  mistaken  for  a  perforation  of  the 
bone ;  its  base  is  limited  by  a  prominent  osseous  border,  which,  how- 
ever, is  often  not  developed  for  several  days  after  the  commencement 
of  the  disease ;  and  the  skin  covering  it  is  colorless.  Again,  the  caput 
succedaneum  appears  directly  after  birth,  and  disappears  in  from 
twelve  to  forty-eight  hours,  while  the  cephalsematoma  seldom  appears 
until  some  hours  after  the  delivery,  and  lasts  for  several  weeks. — 
•Cazeaux. 


358    '  KING'S  ECLECTIC  OBSTETEICS. 


CHAPTER   XXIX. 

ON    DIFFICULT   LABOR — FIRST   STAGE. 

DIFFICULT,  lingering,  tedious,  and  protracted  labor,  belongs  to  the 
second  class,  and  includes  all  labors  where  the  fetal  head  presents,  but 
where  they  continue  beyond  twenty-four  hours,  and  may  require  some 
medicinal,  manual,  or  instrumental  aid.  It  is  true,  that  cases  will  be 
met  with,  in  which  artificial  delivery  may  be  required  within  the  twenty- 
four  hours,  and  others,  again,  which  may  continue  for  a  period  con- 
siderably beyond  twenty-four  hours,  but  these  instances  form  exceptions 
to  the  above  definition.  As  a  general  rule,  however,  the  one  given 
will  be  found  exceedingly  salutary  and  beneficial  in  practice,  and  an 
attention  to  which,  will  be  calculated  to  prevent  the  occurrence  of  any 
mischief  from  a  rash  or  premature  interference  of  the  practitioner. 
This  class  of  labor  has  also  been  termed  unnatural,  but  as  I  can  see  no 
especial  reason  for  changing  the  terms  usually  applied  to  it,  and  which 
in  my  opinion  much  better  express  the  character  of  the  labor,  I  still 
adhere  to  the  designation  "  difficult,"  which  comprises  every  descrip- 
tion of  labor  in  which  the  process  fails  to  be  accomplished  in  a  prompt 
and  regular  manner. 

The  danger  in  a  difficult  labor  depends  entirely  upon  the  stage  in 
which  the  delay  happens ;  thus,  the  first  stage  of  labor  may  continue 
for  even  sixty  or  seventy  hours,  with  but  little,  if  any  danger,  espe- 
cially if  the  membranes  remain  entire,  and  there  is  a  proper  amount 
of  liquor  amnii  present,  and  no  mechanical  impediment  exists.  But 
delay  in  the  second  stage,  is  always  attended  with  danger,  if  it  con- 
tinues beyond  a  comparatively  short  time ;  hence,  in  estimating  the 
necessity  for  interference,  we  are  not  to  be  governed  so  much  by  the 
length  of  time  occupied  by  the  first  stage,  as  by  the  interval  which  has 
elapsed  since  the  rupture  of  the  membranes  and  the  discharge  of  the 
amniotic  fluid ;  and  the  experience  of  accoucheurs  has  demonstrated 
that  the  danger  is,  commonly,  in  proportion  to  the  duration  of  the 
labor.  From  statistics  of  the  Dublin  Lying-in-Hospital,  it  appears 
that  when  labor  exceeds  thirty  hours,  one  woman  in  thirty-four  dies ; 
when  it  exceeds  forty  hours,  one  in  thirteen  dies ;  beyond  fifty  hours, 
one  in  eleven ;  and  beyond  sixty  hours,  one  in  eight. 

Difficult  labors  are  more  common  among  primiparae,  and  are,  like- 
wise, not  unfrequent  among  multipart  who  have  given  birth  to  a  large 
number  of  children.  According  to  the  statistics  of  English  obstetri- 


DIFFICULT    LABOK FIRST    STAGE.  350 

cians,  653  cases  of  difficult  labor  occurred  in  23,758,  or  about  1  in  36 ; 
and  it  will  frequently  happen,  that  a  practitioner  in  his  individual 
private  practice,  may  meet  with  even  a  much  larger  average  than  this. 

The  continuance  of  a  labor  beyond  a  period  of  twenty-four  hours  is 
necessarily  calculated  to  arouse  the  fears  of  the  patient  and  her  friends, 
as  to  the  cause  of  the  delay  ;  and  if  the  practitioner  does  not  proceed 
properly  in  such  instances,  the  anxieties  and  doubts  of  the  friends  may 
lead  them  to  require  the  aid  of  a  second  accoucheur,  or  perhaps  the 
dismissal  of  the  first.  It  is  therefore  always  proper,  when  the  labor 
has  continued  thus  long,  to  institute  a  careful  investigation  of  the  con- 
dition of  the  patient,  arid  of  all  the  presenting  symptoms,  for  the 
purpose  of  learning  the  cause  of  the  delay,  and  at  once  applying  the 
remedy.  "  In  estimating  lingering  labors,  we  calculate  from  the  first 
commencement  of  true  uterine  action  ;  but  in  estimating  the  length  of 
labor,  in  reference  to  the  patient's  strength  and  its  effects  on  her  sys- 
tem, we  principally  take  into  consideration  the  time  that  has  elapsed 
since  the  membranes  broke ;  for  it  is  reasonable  to  infer  that  no  great 
exertion  has  been  sustained,  consequently  that  little  or  no  exhaustion 
has  appeared;  and  particularly,  that  scarce  any  injurious  pressure  can 
have  taken  place  on  the  soft  parts  within  the  pelvis,  while  the  mem- 
branous cyst  remained  entire,  provided  there  be  an  ordinary  quantity 
of  liquor  amnii.  Thus,  when  called  to  a  case  of  lingering  labor,  in 
considering  the  chance  of  injury  from  its  duration,  our  mind  should 
be  directed,  not  so  much  to  the  interval  which  has  elapsed  since  the 
first  accession  of  uterine  pains,  as  to  the  time  at  which  the  membranes 
ruptured  ;  and  that  should  be  looked  upon  as  the  period  when  it  was 
possible  for  dangerous  pressure  to  have  commenced." — Ramsbotham. 

The  management  of  a  patient  in  difficult  labor  must  be  similar  to 
that  required  in  natural  labor.  She  should  not  be  kept  in  one  posi- 
tion, but  should  be  allowed  to  sit,  walk,  or  lie  down,  as  she  may  prefer,, 
and  more  especially  in  the  early  part  of  labor ;  in  the  latter  stage,, 
circumstances  may  require  her  to  preserve  the  recumbent  posture.  She 
must  not  bear  down  or  make  any  efforts  to  assist  the  uterus  during  it* 
contractions,  as  such  efforts  may  cause  the  membranes  to  give  way 
prematurely,  exhaust  the  patient's  strength  uselessly,  or  otherwise 
interfere  with  the  progress  of  the  delivery ;  and  this  is  a  point  which 
can  not  be  too  strongly  insisted  upon.  It  is  only  during  the  second 
stage  of  labor,  when  the  presentation  and  position  are  both  favorable, 
that  the  action  of  the  muscles  of  the  abdomen  may  be  exerted  with 
advantage.  The  room  should  be  kept  cool  and  quiet,  to  prevent  fever 
and  induce  sleep.  Bland,  nourishing  fluids,  weak  tea,  or  acidulated 


360  KING'S  ECLECTIC  OBSTETRICS. 

• 

draughts,  may  be  allowed,  but  stimulants  and  solid  food  must  be  pro- 
hibited. Too  frequent  vaginal  examinations  are  injurious,  but  the 
condition  of  the  bladder  should  be  ascertained  every  two  or  three 
hours,  and  much  urine  should  not  be  allowed  to  collect  in  it.  This  is 
of  especial  importance  in  difficult  labors :  the  urine  must  be  passed 
often,  either  naturally  or  by  catheter ;  and  in  the  use  of  the  latter,  no 
force  should  be  employed,  and  care  must  be  taken  not  to  permit  it  to 
slip  into  the  bladder.  If  the  metallic  instrument  can  not  be  intro- 
duced, an  elastic  catheter  must  be  substituted ;  and  although  under 
ordinary  circumstances  no  exposure  of  the  female  is  allowable,  yet 
there  may  be  instances  where,  from  the  failure  in  introducing  the 
above  instrument,  and  the  condition  of  the  parts,  an  exposure  will  be 
necessary  to  accomplish  the  desired  evacuation  of  the  bladder.  This, 
however,  must  never  be  practiced,  except  under  the  most  imperative 
requirements.  This  class  of  labor  may  be  owing  to  one  or  more  of 
several  causes,  referable  to :  1,  the  uterus;  2,  the  parts  or  passages 
through  which  the  child  passes ;  or,  3,  to  the  child  itself,  and  which  I 
shall  now  proceed  to  designate  and  treat  upon  : 

1. — Among  the  abnormal  conditions  of  the  uterus,  that  may  occur 
during  the  first  stage  of  labor  may  be  named  as  a  very  common  cause 
of  protracted  labor,  INEFFICIENT  ACTION  OF  THE  UTERUS, 
in  which  the  contractions  are  partial,  feeble,  or  irregular ;  they  may 
continue  only  for  a  few  seconds,  they  may  hardly  be  appreciable,  or 
they  may  occur  at  irregular  and  lengthy  intervals ;  and  in  each 
instance,  the  os  uteri  may  be  soft  and  dilatable.  This  cause  will, 
in  some  cases,  be  owing  to  a  torpid,  inactive,  and  sluggish  condition 
of  both  mind  and  body,  or  a  want  of  tone  or  proper  nervous  irrita- 
bility in  the  constitution  ;  to  some  depressing  action,  as  debility  result- 
ing from  excessive  discharges,  previous  disease,  etc.;  to  sudden  and 
violent  emotions  of  the  mind,  and  other  circumstances  which  exert  an 
influence  on  the  brain  and  nervous  system.  Debility  of  the  system, 
or  even  the  presence  of  serious  disease,  does  not  invariably  occasion 
inertia  of  the  uterus,  for  we  frequently  meet  with  females  laboring 
under  tubercular  phthisis,  hectic  fever,  etc.,  who  pass  through  their 
labors  with  great  facility.  With  some  females  the  tendency  to  difficult 
or  easy  deliveries  appears  to  be  a  peculiarity  transmitted  from  parent 
to  child,  and  occurs  independent  of  any  abnormal  conformation,  or 
habit  of  the  system.  A  deranged  condition  of  the  digestive  organs 
will  frequently  influence  the  character  of  the  uterine  contractions,  as 
will  likewise  irritation  of  the  os  or  cervix  uteri.  Cancer  of  the  uterus, 


DIFFICULT    LABOR FIRST    STAGE.  361 

fibrous  tumors,  uterine  inflammation,  rheumatism  of  the  uterus,  etc., 
may  also  interfere  with  the  uterine  contractions,  rendering  them 
deficient  in  dilating  or  expelling  power,  and  irregular  in  their  intervals, 
but  these  causes  are  more  apt  to  prove  dangerous  during  the  second 
stage,  and  will,  therefore,  be  more  particularly  noticed  hereafter. 

Females  are  often  annoyed,  at  the -close  of  gestation,  with  false, 
spasmodic,  or  irritable  pains,  which  have  no  connection  whatever  with 
the  contractions  in  the  fibers  of  the  uterus,  and  which  have,  in  some 
instances,  given  rise  to  the  absurd  statements  that  labor  has  continued 
uninterruptedly  for  one,  two,  or  more  weeks.  Care  should  be  taken 
to  distinguish  these  from  the  proper  contractions  of  the  uterus. 

Inefficient  action  of  the  uterus  may  occur  during  the  first  or  second 
stage ;  and,  as  before  remarked,  the  danger  is  greater  in  the  latter 
than  in  the  former  instance.  In  the  First  Stage  we  may  find  the  pains 
feeble  or  irregular,  and  exerting  but  little  influence  upon  the  bag  of 
membranes ;  yet  if  there  is  only  a  slight  increase  of  the  pulse,  "  with 
the  surface  of  the  body  cool,  tongue  moist,  absence  of  thirst,  no  tender- 
ness of  the  abdomen  on  pressure,  no  heat  or  tenderness  of  the  vagina 
and  os  uteri,  and  dilatation  is  advancing,  however  slowly,  we  ought 
not  to  interfere,  for  many  hours  may  elapse  before  this  stage  will  be 
completed,  and  yet  the  pressure  of  the  fetal  head  upon  the  soft  parts 
will  produce  no  evil  effects  if  the  apartment  be  kept  cool,  the  posture 
be  occasionally  changed,  voluntary  efforts  at  bearing  down  be  avoided, 
and  nothing  but  mild  nourishment  and  diluents  be  allowed." 

TREATMENT. — When  there  is  considerable  delay  in  the  advance- 
ment of  the  first  stage  of  labor,  the  patient  should  be  kept  in  as 
cheerful  condition  as  possible,  and  she  may  occupy  the  time  by 
walking  about — but  not  to  cause  fatigue — by  reading  or  sewing,  by 
frequently  changing  her  position,  etc.;  and  should  be  encouraged  to 
exercise  patience,  which  virtue  the  practitioner  will  find  equally 
demanded  on  his  part.  If  the  bowels  have  not  been  freely  evacuated, 
a  stimulating  enema  or  a  dose  of  purgative  medicine  may  be  given, 
and  which  will  frequently  arouse  the  uterus  to  increased  action.  If 
the  pulse  is  weak  and  slow,  and  no  heat,  but  rather  coolness  of  the 
surface,  nor  hemorrhage,  some  arrowroot,  or  gruel,  or  wine  and  water, 
may  be  beneficial,  but  their  use  should  be  permitted  with  caution. 
If,  from  the  want  of  sleep,  continued  suffering,  and  anxiety  of  mind,  the 
patient  should  become  fatigued  or  exhausted,  a  soporific  dose  of  some 
desirable  agent  should  be  administered,  and  natural  sleep  encouraged, 
indulging  her  in  rest  and  sleep  for  one  or  two  hours;  upon  awaken- 
ing, she  will  not  only  feel  refreshed,  but  will  very  likely  have  a 


362  KING'S  ECLECTIC  OBSTETRICS. 

recurrence  of  the  pains  with  increased  energy.  If  an  opiate  is  admin- 
istered, it  should  always  be  preceded  by  a  purgative  when  constipation 
exists.  In  a  number  of  instances  I  have  succeeded  in  restoring  nor- 
mal power  and  proper  intermittent  action  to  the  uterus  solely  by  the 
administration  of  Sulphate  of  Quinia  in  a  five  or  ten  grain  dose. 

If  there  is  a  plethoric  condition  of  the  uterus,  or  an  irritated  state 
of  the  os  and  cervix  uteri,  this  may  be  frequently  overcome  by  the 
use  of  the  sedative,  which  will  usually  be  Aconite,  in  addition  with 
the  specially  indicated  agents,  as  Macrotys,  Lobelia,  Gelsemium,  or 
Pulsatilla,  as  they  may  be  severally  indicated,  together,  in  some  cases, 
with  the  compound  powder  of  Ipecacuanha  and  Opium.  Plethora 
of  the  uterine  tissue  may  be  known  by  the  energy  with  which  the 
pains  are  at  first  manifested,  but  which  soon  diminish  in  frequency 
and  intensity.  The  cervix  is  soft  and  yielding,  but  the  presenting 
part  does  not  engage  during  the  pain;  the  pulse  is  hard  and  full,  the 
respiration  laborious,  and  the  pains  are  equally  diffused  over  the  whole 
abdomen. 

Sometimes  the  employment  of  warm  diluent  drinks,  with  frictions 
over  the  abdomen,  will  frequently  succeed  in  restoring  or  increasing 
the  contractions,  without  other  aid  being  required. 

When  the  pains  which  occur  at  very  irregular  periods  are  confined  to 
the  uterus,  and  do  not  render  the  bag  of  waters  tense,  nor  impart  any 
hardness  to  the  uterus  when  felt  through  the  abdominal  parietes,  the 
pulse  being  quick  and  full,  and  the  uterus  unusually  developed,  the 
inertia  is  owing  to  an  Excess  of  Liquor  Amnii,  overdistending  the 
organ,  or  perhaps  to  the  presence  of  Twins.  In  this  case,  although 
the  soft  parts  are  relaxed  and  dilated  or  dilatable,  the  labor  does  not 
progress  any,  the  uterus  being,  from  this  cause,  rendered  incapable  of 
contracting  sufficiently  powerful  to  rupture  the  membranes,  and  the 
patient  becomes  fretful  and  restless.  The  only  remedy  in  this  case,  is 
a  discharge  of  the  liquor  amnii  by  an  artificial  rupture  of  the  mem- 
branes, which  should  be  done  during  the  absence  of  pain  [the  os  uteri 
being  well  dilated],  and  made  as  high  up  as  possible,  in  order  to  avoid 
a  falling  or  washing  down  of  the  cord;  though  I  would  especially 
desire  to  impress  it  upon  the  mind  of  the  student  that  this  procedure 
is  entirely  unjustifiable  in  ordinary  labors,  and  must  not  be  attempted 
unless  it  is  well  ascertained  that  there  is  no  mechanical  impediment, 
that  the  head  presents,  and  the  os  uteri  is  dilatable.  A  premature 
rupture  of  the  membranes,  by  discharging  the  bag  of  waters  and- 
bringing  the  hard  and  unyielding  head  of  the  child  upon  the  sensi- 
tive os  uteri,  may  delay  the  labor  by  lessening  the  pains,  or  producing 


DIFFICULT    LABOR — FIRST    STAGE.  363 

rigidity  of  the  os.  Still-born  children  are  more  frequently  the  results 
of  too  early  rupture  of  the  membranes,  and,  probably,  the  use  of  in- 
struments are  likewise  oftener  required  in  such  cases. 

If  the  relaxation  or  cessation  of  uterine  contractions  depends  upon 
moral  influences,  the  attendant,  by  ascertaining  the  trouble,  may  per- 
haps, by  a  prudent  and  sagacious  course,  remove  them ;  but  if  this 
is  impossible,  he  will  be  governed  by  the  effects  produced,  using 
stimulants  in  case  of  depression,  and  sedatives  where  much  nervous 
excitement  exists ;  Pulsatilla  is  likewise  an  excellent  remedy,  espe- 
cially where  there  are  unpleasant  sensations  with  the  nervous  excite- 
ment, the  patient  complaining  that  "there  is  something  n-rony  ivith  the 
child."  The  induction  of  sleep,  also,  will  frequently  be  followed  by 
uterine  efforts. 

I  am  decidedly  opposed  to  the  use  of  Ergot  during  the  first  stage 
of  labor,  where  the  only  difficulty  is  the  inefficiency  of  the  uterine 
contractions,  for,  as  a  general  rule,  an  attention  to  the  various  symp- 
toms which  may  present  themselves,  during  this  stage,  with  their 
appropriate  treatment,  will  be  all  that  is  demanded.  But,  should 
circumstances  require  the  use  of  agents  which  exert  a  parturient  in- 
fluence upon  the  uterus,  Macrotys,  Aconite  and  Macrotys,  or  Pul- 
satilla if  the  patient  is  nervous,  will  prove,  as  a  general  rule,  more 
salutary  than  the  Ergot.  Occasionally  females  will  be  met  with,  upon 
whose  uterine  systems  these  agents  produce  but  little  if  any  influence, 
and  in  whom,  under  imperious  circumstances,  it  may  become  neces- 
sary to  administer  Ergot,  but  I  shall  have  occasion  to  refer  to  these 
cases  hereafter,  as  well  as  to  others  in  which  Ergot  may  be  employed. 
Usually,  however,  the  remedies  above  noticed,  both  during  the  first 
and  second  stages  of  labor,  will  prove  fully  as  efficacious  as  Ergot, 
without  any  of  its  injurious  tendencies.  As  heretofore  observed,  I 
have  found  that  Sulphate  of  Quinia  will  frequently  correct  the  ineffi- 
cient action  of  the  uterus.  Want  of  pain,  or  tardy  pains,  are  met  by 
Lobelia  in  some  cases,  which  may  be  given  with  the  Macrotys  if  there 
is  a  fullness  and  oppression  of  the  pulse. 

2.— RHEUMATISM  OF  THE  UTERUS  may  be  present  during 
the  non-gravid  condition  of  the  organ,  at  an  early  period  of  gestation, 
and  at  the  time  of  labor  during  either  of  its  stages.  It  is  produced 
by  the  same  causes  that  favor  the  development  of  rheumatism  in  other 
parts,  as  exposures  to  cold  and  moisture,  insufficient  clothing,  sudden 
changes  of  temperature,  especially  from  a  high  to  a  low  one,  and 


364  KING'S  ECLECTIO  OBSTETRICS. 

occasionally,  from  a  rheumatic  metastasis;  females  constitutionally 
disposed  to  rheumatism  are  more  liable  to  it,  though  it  frequently 
r\i<ts  without  any  other  part  of  the  system  being  affected  by  it. 

"The  most  prominent  symptom  of  this  disease  is  pain,  or  a  dis- 
tresssing  sensation,  without  any  appreciable  cause,  and  which  may 
involve  the  whole  or  only  a  portion  of  the  uterus.  The  intensity  of 
the  pain  is  variable,  and  the  whole  organ  may  suffer  from  it,  or  only  a 
part,  as  the  fundus,  corpus,  or  cervix.  The  location  of  the  pain 
depends  upon  the  portion  of  the  organ  which  is  affected;  thus  if  it  be 
seated  in  the  fundus,  the  sub-umbilical  region  will  suffer  the  most; 
if  in  the  inferior  portion  of  the  uterus,  acute  dragging  sensations  will 
be  experienced  extending  from  the  loins  to  the  groins,  thighs,  and 
external  genital  organs.  Pressure  upon  the  organ  augments  the  pain, 
and  if  the  inferior  part  of  the  womb  be  affected,  much  suffering  will 
be  caused  by  pressure  upon  the  cervix  during  a  vaginal  examination. 
Frequently  the  contractions  of  the  abdominal  muscles,  or  even  the 
weight  of  the  bedclothes,  will  increase  the  pain.  The  pains,  as  with 
all  rheumatic  affections,  frequently  metastasize,  and  pass  from  one 
point  of  the  organ  to  another,  or  to  some  other  organ,  and  not  un  fre- 
quently disappear  suddenly.  Remissions  occur  sometimes,  during 
which  a  sensation  of  weight  in  the  part  is  experienced.  Recto-vesical 
tenesmus  almost  always  accompanies  the  pain,  and  the  evacuation  of 
urine  is  attended  with  considerable  smarting  and  acute  pain,  and  at 
other  times  the  evacuation  of  both  the  bladder  and  rectum  is  impos- 
sible. The  pain  is  usually  attended  with  febrile  symptoms,  but  some- 
times these  are  absent.  A  repetition  of  the  attacks  of  pain  is  very 
apt  to  occasion  uterine  contractions,  which  may  determine  an  abortion. 

"  When  rheumatism  of  the  uterus  occurs  during  labor,  it  generally 
impedes  the  progress  of  the  labor,  and  sometimes,  even  prevents  the 
spontaneous  expulsion  of  the  child.  Normal  contractions  of  the 
uterus  only  begin  to  be  painful,  when  it  has  accomplished  the  greater 
part  of  its  task,  and  is  in  the  act  of  distending  and  dilating  the  os 
uteri;  or  in  other  words,  true  labor-pains  begin  only  at  the  instant 
when  the  energy  of  the  corpus  uteri  overcomes  the  resistance  of  the 
cervix.  While  in  rheumatism  of  the  uterus,  the  contraction  is  painful 
from  the  first,  and  before  any  influence  is  exerted  on  the  cervix ;  so 
that  the  cause  of  the  pain  is  not  in  the  violent  distension  of  the  os 
uteri,  but  in  the  contraction  itself,  in  the  other  morbid  conditions  and 
in  the  altered  relations  of  the  nerves  and  contractile  fibers  of  the 
uterus. 

"  Again,   in    a   natural    labor,  the   contractions   commence   at   the 


DIFFICULT     LABOR — FIRST    STAGE.  365 

fundus,  and  are  directed  toward,  and  terminate  at  the  cervix.  In 
rheumatism,  instead  of  commencing  at  the  fundus,  they  begin  at  the 
painful  part,  and  run  toward  the  cervix  in  an  irregular  manner.  The 
rheumatic  pains  also  exist  before  the  uterine  contractions,  and  under 
the  influence  of  the  latter,  they  rapidly  acquire  a  high  degree  of 
intensity ;  and  sometimes  their  violence  arrests  the  contractions  before 
they  have  traversed  their  ordinary  cycle,  in  which  case  they  are  rapid, 
short,  and  grow  less  and  less  frequent. 

"  Toward  the  close  of  the  labor,  when  the  action  of  the  uterus 
requires  to  be  aided  by  the  voluntary  contraction  of  the  abdominal 
muscles,  the  female,  for  fear  of  augmenting  her  sufferings  refrains 
from  contracting  these  muscles,  thereby  causing  the  labor  to  be  ex- 
cessively slow.  She  is  in  a  state  of  extreme  anxiety,  with  an  increase 
of  the  frequent  pulse,  the  hot  skin,  the  thirst,  and  urinary  tenesmus. 
When  these  sufferings  are  much  prolonged,  she  falls  into  a  state  of 
swooning,  which  frequently  proves  serviceable,  as  the  pains  are 
suspended  while  it  lasts;  under  these  circumstances  a  profuse  perspira- 
tion has  been  observed,  which  has  had  a  most  salutary  influence  on  the 
rest  of  the  labor.  But,  in  other  instances,  the  uterus  becomes  more 
and  more  painful;  it  is  rather  in  a  state  of  permanent  contraction 
or  fibrillar  vibration,  than  of  normal  contraction ;  the  pulse  being 
accelerated,  and  the  woman  threatened  with  a  metritis,  which  renders 
the  labor  extremely  painful." — Cazeaux. 

Uterine  rheumatism  is  frequently  mistaken  for  acute  inflammation 
of  the  womb,  and  as  the  symptoms  resemble  each  other  very  much,  it 
is  very  difficult  to  discriminate  between  them.  Rheumatism  attacks 
mostly  very  nervous  and  susceptible  women,  and  may  be  more  readily 
suspected  when  the  patient  has  had  previous  attacks  of  rheumatism  or 
neuralgia,  in  other  parts.  Cazeaux  determined  the  disease  by  touch- 
ing; thus,  rheumatism  and  inflammation  of  the  uterus  are  both  painful ; 
but  in  rheumatism,  although  the  first  touch  of  the  womb  is  painful  and 
quick,  yet  upon  gently  and  slowly  raising  it  upward  with  the  index 
and  middle  finger,  the  pain  either  ceases  altogether,  or  is  much  miti- 
gated, by  removing  the  tenesmus  uteri ;  while  in  inflammation  the 
touch  becomes  mo're  painful  the  more  it  is  prolonged. 

TREATMENT. — The  means  which  may  be  adopted  with  benefit  in 
these  cases  are  various.  In  the  first  place  the  bowels,  if  they  have 
not  been  previously  evacuated,  must  be  emptied  by  an  injection ;  if 
the  pain  be  not  very  severe,  but  troublesome  and  annoying,  the  com- 
pound powder  of  Ipecacuanha  and  Opium  may  be  given,  in  doses  of 
three  to  five  grains,  and  repeated  every  half-hour  or  hour;  other 


366  KING'S  ECLECTIC  OBSTETRICS. 

agents,  however,  will  usually  be  called  for,  and  among  the  first  Ma- 
crotys  should  be  thought  of,  and  in  many  cases  will  be  all  that  is 
needed.  If  the  pain  is  attended  by  an  excited  circulation,  Aconite 
should  be  added,  always  observing  the  usual  small  dose.  If  the  pain 
is  inclined  to  extend  down  the  thighs,  and  to  the  region  of  the  back, 
Pulsatilla  may  be  given  with  the  Macrotys.  If  there  are  marked 
remissions,  Quinine  may  be  given  in  doses  of  three  to  six  grains,  and 
repeated  as  often  as  seems  necessary.  Fomentations  of  Stramonium 
leaves,  or  other  narcotics,  may  also  be  advantageously  applied  over 
the  abdomen,  and,  when  the  pain  is  very  severe,  much  benefit  will 
be  derived  from  the  application  of  dry  cups  over  the  lateral  inferior 
portions  of  the  sacrum.  Should  the  disease  manifest  itself  soon  after 
the  sudden  disappearance  of  a  rheumatic  pain  in  some  other  part, 
revulsives  or  counter-irritants  should  be  placed  over  the  part  pri- 
marily affected,  for  the  purpose  of  recalling  the  pain,  if  possible,  to 
that  part. 

Other  means  may  likewise  be  used  in  some  cases,  in  addition  to 
those  just  named;  Lobelia  may  be  indicated  by  the  unpleasant  sense 
of  weight  and  dragging  in  the  abdomen  and  pelvis,  or  if  the  pains 
are  associated  with  a  sense  of  muscular  debility  Nux  Vomica  will  be 
the  remedy. 

The  disposition  to  uterine  rheumatism  at  the  period  of  labor 
may,  in  most  instances,  be  entirely  overcome  by  the  use  of  the 
Parturient  Balm  during  gestation.  General  venesection,  although 
it  may  afford  relief,  is  never  necessary,  as  its  results  are  ultimately 
more  disastrous  to  the  patient  than  beneficial,  and  a  more  per- 
manent advantage  is  gained  over  the  disease  by  the  above  course, 
than  could  possibly  be  effected  by  the  employment  of  the  lancet ;  and 
by  pursuing  it,  there  will  exist  but  little  necessity  for  forceps,  unless 
other  symptoms,  not  immediately  connected  with  the  rheumatic  attack, 
are  present. 

3.— RIGIDITY  OF  THE  OS  UTERI,  during  the  first  stage  of 
labor,  is  a  frequent  cause  of  its  protractedness.  This  may  occur  in 
any  case,  but  is  more  frequently  met  with  in  primiparse,  in  females  of 
an  advanced  age,  and  in  instances  where  the  membranes  are  prema- 
turely ruptured.  It  may  be  occasioned  by  repeated  and  unnecessary 
examinations,  the  use  of  stimulants,  mental  excitement,  constipation, 
or  retained  urine.  It  may  also  be  owing  to  dysmenorrhea,  or  a  dis- 
eased condition  of  the  os  itself,  either  natural,  or  effected  by  the 
improper  use  of  pessaries  or  other  mechanical  aids  to  support  the 


DIFFICULT    LABOR — FIRST   STAGE.  367 

uterus,  as  well  as  the  imprudent  application  of  escharotics  to  the  os, 
for  the  removal  of  some  real  or  imaginary  affection. 

Rigidity  of  the  os  uteri  may  be  suspected  in  cases  where  the  head 
.presents  and  the  pains  are  regular  and,normal,  but  dilatation  proceeds 
very  slowly,  if  at  all ;  the  pains  gradually  lose  their  force,  and  the 
patient  becomes  exhausted ;  in  addition  to  which,  Madam  La  Chapelle 
refers  to  another  symptom,  viz.:  pains  in  the  loins.  On  examination, 
the  os  uteri  will  be  found  thin,  resisting,  hot,  dry,  and  painful  to  the 
touch,  or,  soft,  cedematous,  semi-pulpy,  and  undilatable,  and  which 
must  be  carefully  distinguished  from  the  soft  and  flabby  condition  into 
which  the  thin  and  rigid  cervix  must  pass  before  it  will  dilate.  Some- 
times the  rigidity  is  excessive,  the  os  being  unusually  dense,  feeling  like 
cartilage,  with  a  stubbornly  unyielding  edge ;  or  if  this  be  thin,  the 
same  resistance  will  be  met  with,  and  a  sensation  is  conveyed  to  the 
touch,  similar  to  that  produced  by  a  hole  made  in  thin,  extended 
parchment. 

Very  frequently  the  rigidity  will  not  be  confined  to  the  os  uteri, 
but  will  extend  into  the  vagina  and  soft  parts ;  they  will  be  found  hot, 
dry,  swollen,  and  extremely  sensitive  to  the  touch,  and  if  this  condition 
be  not  overcome,  the  patient  becomes  restless  and  feverish,  the  pulse 
rises  to  100  or  110,  and  finally,  exhaustion  of  the  vital  forces  mani- 
fests itself.  Occasionally  the  os  uteri  will  be  found  to  contract  during 
a  pain,  remaining  rigid  in  the  interval ;  and  in  such  instances  a  rup- 
ture of  the  uterus  may  occur.  Instances  are  recorded  in  which  the 
rigidity  was  so  obstinate  that  the  os  uteri  has  been  torn  off  and  expelled 
in  the  form  of  a  ring. 

TREATMENT. — Formerly  venesection,  ad  deliquum  animi,  was 
considered  the  most  successful  and  potent  remedy  in  this  difficulty, 
and  was  the  one  on  which  the  utmost  reliance  was  placed  by  the 
major  part  of  the  profession.  I  admit  that  bleeding  will,  in  most 
cases,  have  the  effect  of  overcoming  rigidity  of  the  os  uteri,  but  I  by 
no  means  admit  it  to  be  a  proper  or  safe  remedy.  A  female  in  labor 
requires  all  the  strength  natural  to  her  system,  not  only  to  sustain 
her  during  its  progress,  but  also  to  enable  her  to  withstand  and 
quickly  recover  from  the  nervous  shock.  By  the  loss  of  an  amount 
ot  blood  sufficient  to  cause  syncope,  a  debility  of  the  nervous  and 
circulatory  systems  must  ensue,  producing  a  condition  unfavorable 
to  either  of  these  requirements;  and  a  tedious  second  stage,  with 
subsequent  hemorrhage  or  other  evils,  frequently  followed  a  bleed- 
ing practiced  in  the  first  stage,  and  which,  no  doubt,  were  aug- 
mented, if  not  actually  produced,  by  the  venesection.  Debility  of  the 


368  KING'S  ECLECTIC  OBSTETRICS. 

system,  and  more  especially  when  sudden,  persistent,  and  at  the  period 
of  parturition,  is  incompatible  with  a  safe  or  energetic  labor.  Beside 
the  weakening  influence  of  venesection  upon  the  constitution,  we  have 
an  increased  prostration  of  nervous  and  muscular  force,  produced  by 
the  shock  imparted  to  the  brain  and  nervous  system,  as  well  as  by  the 
lo.-s  of  blood  which  necessarily  follows  the  birth  of  every  child.  In- 
deed, it  is  impossible  for  any  practitioner  to  determine  what  amount 
of  blood  may  be  lost  from  the  labor  itself,  independent  of  any  artificial 
discharge;  and  who  can  tell  hew  many  precious  lives  have  been  lost 
from  uterine  hemorrhage,  or  other  fatal  symptoms,  in  the  practice  of 
believers  in  this  treatment,  which  might  have  been  preserved  had  the 
lancet  been  cast  aside?  Indeed,  so  well  were  the  adherents  of  this 
practice  satisfied  of  its  danger  to  the  parturient  woman,  that  they 
especially  advised  not  to  resort  to  it  until  the -parts  become  swollen 
and  tender,  the  pulse  increased,  with  febrile  symptoms,  or  a  tendency 
to  cerebral  congestion ;  and  even  then  to  use  it  with  great  care.  The 
injurious  tendencies  of  bleeding  do  not  cease  with  the  completion  of 
delivery,  for,  whether  it  be  artificially  effected  by  the  lancet,  or  nat- 
urally by  uterine  hemorrhage,  not  only  is  the  puerperal  month  one 
of  slow,  tedious  convalescence,  if  this  term  can  justly  be  applied  to 
it,  but  very  frequently  a  life-time  of  irremediable  suffering  and  dis- 
ease is  the  inevitable  consequence.  Tartar  Emetic  was  also  a  favor- 
ite remedy  of  the  champions  of  venesection,  and  was  administered  in 
nearly  every  case  of  rigidity  of  the  os. 

In  the  treatment  of  this  difficulty,  u-e  "have  no  occasion  to  wait  for 
the  appearance  of  the  above  symptoms  before  attempting  relief,  be- 
cause we  have  means  to  subdue  it  without  the  infliction  of  any  imme- 
diate or  permanent  injury  to  the  system,  and  as  soon  as  the  evil  man- 
ifests itself,  we  at  once  apply  the  remedy,  saving  the  patient  a  great 
amount  of  suffering,  and  the  friends  and  ourselves  much  anxiety  and 
alarm.  And  hence,  we  believe  our  practice  has  a  vast  advantage  over 
that  which  dare  not  attempt  certain  relief  until  after  a  lengthened 
period  of  pain  and  distress,  and  when  exhaustion  of  the  vital  forces  is 
about  to  commence.  Promptness  in  combating  this  condition,  as  well 
as  many  others,  is  the  only  method  by  which  to  insure  certainty  of 
success. 

In  cases  of  rigidity,  during  the  early  part  of  labor,  it  will  be  neces- 
sary to  pay  particular  attention  to  the  evacuation  of  the  contents  of 
the  rectum  as  well  as  of  the  bladder;  if,  after  having  waited  for  ten 
or  fifteen  minutes  subsequently,  the  rigidity  still  remained,  the  old 
time  treatment  of  eclectics  was  to  administer  at  once  the  compound 


DIFFICULT    LABOR FIRST    STAGE.  369 

tincture  of  Lobelia  and  Capsicum,  in  doses  of  one,  two,  or  four  fluid 
drachms,  according  to  the  urgency  of  the  case,  to  be  repeated  in  ten 
or  fifteen  minutes  should  it  be  required;  and,  in  the  generality •  of 
cases,  this  would  effect  a  speedy  and  safe  relaxation.  In  some  cases, 
in  conjunction  with  the  above,  an  injection  of  the  same  tincture  was 
employed,  in  the  quantity  of  half  a  fluid  drachm,  or  a  fluid  drachm 
diluted  with  a  similar  amount  of  water,  requesting  the  patient  to  re- 
tain it  as  long  as  possible.  In  many  instances  this  enema,  it  is  claimed, 
was  sufficient  to  overcome  the  rigidity,  without  the  administra- 
tion of  any  medicine  by  mouth.  This  compound  is  not  at  present 
used,  to  any  great  extent;  it  was,  no  doubt,  a  good  antispasmodic, 
and  was  an  efficient  means  in  overcoming  the  condition  for  Avhich  it 
was  prescribed,  and  was  only  discarded  on  account  of  its  disagreeable 
taste  and  the  large  dose  required.  Lobelia,  or  Gelsemium,  are  the 
specific  agents  now  recommended  for  this  difficulty.  The  emetic  in- 
fluence of  Lobelia  is  not  necessary,  to  produce  the  required  result, 
nor,  indeed,  is  it  always  desirable  that  emesis  should  follow;  much 
more  salutary  and  immediate  results  will  ensue  from  nauseating  and 
relaxing  closes — and  when  vomiting  has  once  occurred  from  its  use, 
without  relaxation,  it  will  frequently  be  found  that  smaller  doses  will 
nob  be  retained  sufficiently  long  upon  the  stomach  to  exert  any  relax- 
ing influence.  Lobelia  is  the  remedy  commonly  indicated;  its  effect 
is  direct  and  certain,  especially  where  the  parts  are  full  and  doughy; 
it  not  only  overcomes  the  rigidity,  producing  dilatation,  but  at  the 
same  time  favors  uterine  contractions.  It  is,  indeed,  one  of  the  most 
valuable  remedies  in  obstetrics.  Gelsemium  is  likewise  an  efficient 
remedy,  and  may  be  used  in  many  cases  with  benefit.  It  possesses  an 
advantage  over  Lobelia,  in  not  causing  nausea  or  vomiting;  but,  as  a 
general  rule,  its  influence  is  not  so  readily  experienced  as  with  that 
agent.  Gelsemium  should  be  selected  when  the  tissues  are  thin  and 
tense,  want  of  secretion,  the  contractions  are  painful,  the  patient  nerv- 
ous, the  vagina  hot  and  dry. 

In  those  cases  where  inflammation  of  the  os  uteri  is  caused  by  un- 
equal pressure  of  the  child's  head  upon  it,  the  Gelsemium  will  be  y 
found  a  valuable  remedy. 

The  induction  of  copious  perspiration,  by  the  spirit  vapor-bath  or 
otherwise,  has  been  advised,  and  will,  probably,  be  found  effectual  in 
some  cases;  but,  on  account  of  the  trouble  attending  its  application 
during  parturition,  and  the  danger  of  chill  subsequently,  it  is  better 
to  employ  it -only  when  imperatively  required. 
24 


370  KING'S  ECLECTIC  OBSTETRICS. 

The  direct  application  of  extract  of  Belladonna  to  the  os  uteri, 
artificial  dilatation,  etc.,  have  been  recommended  by  various  writers, 
but  I  have  never  used  them ;  the  above  means  having  proved  suc- 
cessful in  my  own  practice,  as  well  as  in  that  of  others  presented  to 
my  notice.*' 

*  In  relation  to  manual  dilatation  of  the  os  uteri,  which  has  been  recommended  by 
some  writers,  under  certain  circumstances,  it  may  be  well  for  the  student  to  acquaint 
himself  with  the  following  rules,  given  by  Prof.  Dewees,  which  may  prove  serviceable 
in  the  cases  to  which  he  alludes : 

"  1st.  When  this  part  does  not  coincide  with  the  direction  of  the  uterine  forces,  and 
the  axis  of  the  vagina.  In  this  case,  labor  may  become  very  tedious,  for  the  want  of 
a  correspondence  of  the  axes;  I  therefore  attempt  to  establish  them,  as  directed  in  cases 
of  obliquity  of  the  uterus. 

"  But  I  never  attempt  even  the  slight  change  here  spoken  of,  until  the  os  uteri  is 
yielding,  and  at  the  same  time  dilated,  to  the  size  of  a  dollar,  and  the  pains  in  pretty 
full  force.  By  this  method,  not  the  slightest  violence  is  committed,  nor  is  even  pain 
excited. 

"  2d.  When  the  pains  are  powerfully  protrusive,  and  the  os  uteri,  though  pretty 
amply  dilated,  yet  not  sufficiently  so  to  permit  the  parietal  protuberances  to  pass  freely 
through  it.  In  this  case,  much  time  and  suffering  are  very  often  saved,  by  running 
the  extremity  of  the  finger  round  the  margin  of  the  os  uteri,  and  gently  stretching  it. 
For,  in  many  instances,  if  we  gain  an  increase  of  half  an  inch  in  the  diameter  of  this 
part,  it  is  all  that  is  required,  to  enable  the  head  to  pass  it. 

"3d.  When  the  head  is  detained  by  the  anterior  portion  of  the  uterus  being  in 
advance  of  it,  and  holding  it  as  it  were,  in  a  sling.  In  this  case,  that  portion  of  the 
neck  of  the  uterus,  which  is  placed  before  the  head,  is  obliged  to  sustain  the  whole 
force  of  the  uterine  efforts ;  in  consequence  of  which,  it  becomes  not  only  severely 
stretched,  but  it  very  effectually  opposes  the  advancement  of  the  presenting  part,  and 
gives  rise  to  much  unnecessary  delay,  as  well  as  very  much  augmenting  the  sufferings 
of  the  patient. 

"This  case  is  one  of  very  frequent  occurrence;  and  women  who  have  ample  pelves, 
and  especially  those  who  have  had  several  children,  and  are  liable  to  the  anterior  obli- 
quity of  the  uterus,  are  more  particularly  obnoxious  to  it.  I  do  not  know  that  any 
writer  has  noticed  this  cause  of  tedious  labor;  and  though  this  can  not.  strictly  speak- 
ing, be  considered  as  an  instance  of  rigidity,  it  nevertheless  has  all  the  effects  of  that 
condition,  as  it  creates  delay,  by  a  portion  of  one  of  the  soft  parts  opposing  the  passage 
of  the  head  ;  and  may,  therefore,  with  much  propriety,  be  considered  under  the  present 
head  of  onr  subject. 

"We  are  every  way  satisfied,  from  long  observation,  that  this  situation  of  the  uterus, 
and  of  the  head  of  the  child,  is  one  of  the  most  common  causes  of  delay  when  every- 
thing else  is  favorably  disposed,  that  occurs  in  practice — at  least  in  this  country. 
Whether  this  be  so  in  Europe,  where  the  remote  causes,  namely,  large  pelvis,  are  not  so 
•reneral,  we  are  unprepared  to  say;  but  we  are  certain,  that  the  frequency  of  this 
relation  of  the  head  of  the  child,  and  the  anterior  portion  of  the  uterus,  in  this  country, 
render  such  labors  more  tedious,  by  hours,  than  they  would  be,  if  no  such  interposition 
of  the  neck  of  the  uterus  took  place. 

"It  is  true,  that  the  remora  which  the  neck  of  the  uterus  offers  to  tjie  passage  of  the 
head  when  down  before  it,  never  of  itself  creates  a  serious  difficulty ;  the  evil  chiefly 
consists  in  a  painful  and  unnecessary  delay ;  but  as  the  case  is  always  manageable, 


DIFFICULT    LABOR FIRST   STAGE.  371 

Rigidity  depending  on  disease  of  the  os  uteri  may  be  removed  by 
the  above  plan,  but  it  can  not  always  be  expected  to  answer.  In- 
cising the  cervix  lias  been  advised  as  a  successful  measure  in  those 
cases  which  prove  very  obstinate  and  protracted  ;  but  I  have  never 
had  occasion  to  attempt  the  operation.  The  inhalation  of  Chloro- 


when  it  is  proper  to  offer  aid,  it  is  certainly  right  to  correct  this  deviation  from  a 
strictly  healthy  labor,  as  early  as  circumstances  will  permit. 

"The  proper  time  to  act  is,  when  the  head  occupies  the  inferior  strait  and  vagina, 
completely;  when  the  pains  are  active;  and  when  the  os  uteri  is  sufficiently  dilated 
to  permit  the  head  to  pass,  if  the  axis  of  the  head,  and  that  of  the  os  uteri  were  co- 
incident. 

"To  relieve  the  head  from  this  state  of  embarrassment,  we  must  draw  the  prolapsed 
edge  of  the  os  uteri  by  the  point  of  the  finger,  in  the  absence  of  pain,  toward  the  sym- 
physis  pubis,  and  maintain  it  there,  until  a  pain  comes  on.  At  this  moment,  the  point 
of  the  finger  is  to  be  placed  against  the  edge  of  the  uterus,  which  is  to  be  pushed 
upward  between  the  head  of  the  child  and  the  pubes.  Should  we  be  able  to  carry 
the  prolapsed  portion  of  the  uterus  above  the  advancing  portion  of  the  head,  the 
former  will  suddenly  withdraw  itself  from  the  finger;  the  vertex  will  apply  itself  to 
the  arch  of  the  pubes,  and  the  labor  terminate  almost  immediately. 

"It  sometimes,  however,  requires  several  trials  of  this  kind  before  they  may  succeed; 
but  the  attempt  must  not  be  abandoned  because  it  fails  a  few  times,  for  the  principle 
is  a  correct  one,  and  should,  be  acted  upon  perseveringly,  should  perseverance  be 
necessary.  We  have  everything  to  gain,  if  we  succeed,  and  nothing  to  lose  if  it  fail ;  a 
disappointment,  by-the-by,  which  can  not  well  happen,  if  the  process  for  the  restoration 
of  the  prolapsed  part  be  properly  conducted. 

"We  are  convinced  that  we  have  seen  very  many  labors,  shortened  by  hours,  by 
acting  as  just  proposed  for  such  cases.  It  would  be  extremely  difficult  to  determine,  a 
priori,  the  duration  of  a  labor  of  this  kind,  if  left  to  itself;  as  the  resistance  which  the 
margin  of  the  uterus  offers  to  the  head,  will  for  a  long  time  be  more  than  equal  to  the 
power  of  the  uterine  forces ;  consequently,  the  labor  becomes  stationary,  and  will  con- 
tinue to  be  so,  until  the  margin  of  the  uterus  is  obliged  to  yield,  by  its  losing  a  part  of 
its  power  from  attenuation,  or  perhaps  by  tearing. 

"  Nobody  estimates  the  general  rule,  'to  let  a  labor  alone  that  is  advancing  well, 
and  is  natural  in  its  general  relations,'  more  highly  than  we  do;  we  look  upon  it  as  a 
most  wholesome  restraint  when  acted  upon ;  and  is  every  way  calculated  to  diminish 
ignorant  and  mischievous  officiousness.  But  this  rule,  like  every  oth_er  general  rule, 
has  its  exceptions;  and  we  may  be  even  accused  of  violating  it  unnecessarily,  when 
we  make  the  cases  under  consideration  exceptions;  but  we  should  feel  but  little  con- 
cern upon  this  head,  if  the  charge  be  even  preferred  against  us,  as  we  are  certain  that 
we  are  justified  in  making  them  from  ample  experience. 

"Many,  nay,  perhaps  everybody  (for  we  have  said  that  we  did  not  know  that  this 
case  had  been  noticed),  will  condemn  what  we  have  said  upon  this  subject,  and  con- 
sider our  directions  as  unnecessary,  if  not  mischievous,  because  they  have  never  had 
recourse  to  them,  but  have  permitted  the  uterus  to  perform  this  duty  unaided;  there- 
fore they  say  nature  is  competent  to  the  work,  and  when  she  is  competent,  she  is  not  to 
be  interfered  with.  Were  this  rule  rigidly  acted  up  to,  there  would  be  an  end  to 
improvement,  not  only  in  the  obstetric  art,  but  in  the  whole  range  of  practical  medi- 
cine.  Our  experience,  however,  teaches  us  not  to  heed  this  sweeping,  indiscriminate 
rule;  for  it  is  not  sound  practice  to  permit  nature  to  struggle  through  difficulties, 


372  KING'S  ECLECTIC  OUSTETKICS. 

form  is  a  very  efficacious  remedy  in  overcoming  rigidity  of  the  parts,. 
and  is  used  by  many  in  preference  to  other  means. 

When  the  various  means  recommended  to  subdue  the  rigidity  fail  to 
accomplish  this  result,  and  artificial  delivery  becomes  necessary,  it  is 
recommended  to  complete  the  labor  with  the  forceps,  provided  the  os 
is  fully  dilated,  and  the  fetal  head  has  descended  so  low  into  the  pelvic 
cavity  that  an  ear  can  be  felt.  But  if  the  os  is  not  fully  dilated,  and 
the  greater  part  of  the  fetal  head  remains  above  the  superior  strait, 
and  circumstances  present,  demanding  prompt  delivery  in  order  to 
save  the  mother's  life,  the  perforator  and  crotchet  must  be  employed, 
for  in  such  instances,  the  attempt  to  deliver  by  forceps  would  be  rash 
and  unjustifiable;  however,  it  will  seldom  happen,  unless  in  cases  of 
diseased  os,  that  the  treatment  above  named  will  fail  in  overcoming 
the  rigidity. 

The  tendency  to  this  cause  of  difficult  labor,  as  well  as  of  inefficient 
uterine  contractions,  may  generally  be  obviated  by  a  proper  course  of 
management  through  the  gestating  period,  or  at  least  during  its  latter 
months,  in  all  cases  where  the  physician  is  aware  of  his  selection  as  the 
accoucheur.  For  a  few  months  previous  to  the  expected  labor,  he 
should  explain  and  impress  upon  his  patient's  mind,  the  necessity  and 
advantages  to  be  derived  from  a  proper  preparatory  course,  especially, 
if  any  circumstances  exist,  which  might  lead  him  to  anticipate  a  diffi- 
cult parturition.  The  course  to  be  pursued  at  this  time,  and  which  has 
proved  generally  successful,  is,  to  keep  the  bowels  in  a  normal  condi- 
tion by  diet,  if  possible,  otherwise,  by  mild  laxatives;  avoid  fatigue, 
overstimulus,  and  improper  food,  and  administer  once  or  twice  daily, 
a  dose  of  the  Parturient  Balm,  which  exerts  a  healthy  tonic  influence 
over  the  uterus,  disposing  it  to  act  with  proper  energy  at  the  time  of 
labor. 

merely  because  it  is  supposed  she  can  struggle  through  them;  and  to  leave  it  for 
some  time  a  moot  point,  whether  or  not  the  case  will  eventuate  in  safety,  when  aid,  as 
certain,  as  safe,  is  always  at  command.  Nor  does  this  application  of  the  finger  ever 
produce  pain  or  other  inconvenience,  if  properly  and  gently  managed. 

"Beside  much  delay  is  sometimes  experienced  from  this  dropping  down  of  the 
anterior  portion  of  the  uterus,  by  interrupting  the  pivot-like  motion  of  the  head,  from 
completing  itself;  especially  when  the  head  occupies  pretty  strictly  the  inferior  strait. 
In  this  case,  the  posterior  fontanelle  will  remain  for  a  long  time  stationary  behind  one 
of  the  foramina  ovalia;  for  its  advancement  toward  the  arch  of  the  pubes,  is  prevented 
by  the  prolapsed  portion  of  the  uterus  interfering  with  the  motion  just  mentioned,  by 
embracing  too  strictly  the  advancing  part  of  the  head. 

"  But  the  pivot-like  motion  of  the  head  is  almost  always  restored,  the  instant  we 
succeed  in  passing  the  depending  portion  of  the  uterus  above  the  head  of  the  child  by 
the  point  of  the  finger,  as  directed  above." 


DIFFICULT    LABOR — FIRST   STAGE.  373 

4. — The  proper  position  of  the  uterus  is  when  it  occupies  the  middle 
of  the  abdomen,  with  its  longitudinal  diameter  in  the  direction  of  the 
axis  of  the  superior  strait ;  but  in  persons  of  a  lax  and  flaccid  habit 
of  body,  and  especially  with  those  in  whom  the  walls  of  the  abdomen 
have  become  relaxed,  it  frequently  inclines  anteriorly  or  laterally, 
which  inclination  is  termed  OBLIQUITY  OF  THE  UTERUS,  and 
which  may,  by  producing  rigidity,  or  other  symptoms,  retard  labor ; 
the  positions  of  the  presentations  are  frequently  affected  by  these 
obliquities,  and  the  deviations  of  which,  continue,  in  many  instances, 
even  after  the  uterus  has  been  restored  to  its  normal  situation.  There 
are  three  varieties  of  obliquity  :  an  anterior  obliquity,  in  which,  from 
excessive  relaxation  of  the  abdominal  parietes,  the  fundus  uteri  falls 
forward,  throwing  the  os  uteri  upward  and  backward  in  an  unusual 
degree  ;  a  right  lateral  obliquity,  in  which  the  fundus  falls  toward  the 
right  side  ;  and  a  left  lateral  obliquity,  in  which  it  falls  to  the  left 
side.  Among  these  the  left  lateral  obliquity  is  more  frequently  met 
with.  In  an  anterior  obliquity,  the  female  will  be  very  apt  to  imagine 
herself  larger  than  usual,  or  perhaps,  that  she  will  give  birth  to 
twins.  These  obliquities  may  be  ascertained  by  observing  that  the 
fundus  of  the  uterus  falls  to  the  right,  or  left,  or  anteriorly,  and  that 
the  os  uteri,  instead  of  its  normal  situation  in  the  center  of  the  pelvic 
cavity,  is  directed  laterally  to  the  right,  or  left ;  and  in  the  anterior 
obliquity  it  will  be  found  upward  and  backward,  elevated  to  an  extent 
corresponding,  relatively,  with  the  anterior  inclination  of  the  fundus. 
These  obliquities,  when  excessive,  especially  the  anterior,  have  fre- 
quently given  rise  to  the.  idea  that  the  os  uteri  was  imperforate ;  and 
if  not  readily  recognized  and  overcome,  they  may  occasion  more  or 
less  serious  accidents  to  both  mother  and  child. 

TREATMENT.— This  difficulty  can  be  removed,  by  placing  the 
patient  upon  the  side  opposed  to  the  obliquity,  or  upon  her  back  in 
the  anterior  variety ;  and  when  the  replacement  of  the  uterus  is  ac- 
complished, by  applying  a  bandage  firmly  around  the  body,  the  organ 
may  be  kept  in  its  normal  position.  In  the  early  stage  of  labor,  it 
will  be  found  advantageous,  in  these  cases,  to  keep  the  patient  upon  her 
back,  having  the  shoulders  somewhat  depressed,  and  the  hips  slightly 
elevated.  Any  attempt  to  remove  these  obliquities  by  pulling  upon 
the  os  uteri  is  highly  improper. 

Sometimes  there  is  an  Obliquity  of  the  Os  Uteri  only,  and  this  is 
more  apt  to  procrastinate  the  labor,  than  when  the  whole  organ  is 
inclined.  Upon  an  examination,  the  os  uteri  will  be  found  facing  the 
sacrum,  and  oftentimes  being  difficult  to  reach.  Should  this  condition 
remain  for  any  length  of  time,  without  change,  the  expulsive  efforts 


374  KlXCi's    KCLF.CTIC    OHSTKTKK 'S. 

of  the  uterus  being  necessarily  directed  against  the  anterior  part  of 
the  cervix,  which  occupies  the  open  space  in  the  pelvis,  may,  by 
forcing  the  head  downward,  occasion  a  rupture  at  this  point. 

In  a  case  of  this  kind  the  female  should  be  kept  in  bed  as  much  a> 
possible,  and  as  soon  as  it  can  be  reached,  the  anterior  lip  of  the  os 
should  be  hooked  by  a  finger,  brought  carefully  to  the  center  of  the 
navity  and  sustained  there  until  one  or  more  subsequent  contractions, 
by  pressing  the  head  downward  and  into  the  opening,  will  thus  pre- 
vent the  lip  from  resuming  its  previous  abnormal  position. 

Labor  is  occasionally  protracted  in  consequence  of  the  Anterior  Lip 
of  the  Os  Uteri  being  retained  between  the  head  and  pubic  symphysis. 
either  being  caught  thus  during  the  dilatation,  or  occasioned  by  an 
unequal  dilatation  of  the  anterior  and  posterior  portions  of  the  cervix. 
This  may  delay  the  first  stage  of  labor  for  several  hours.  It  may  be 
overcome  by  the  following  operation,  provided  the  head  does  not  fill 
the  pelvis  too  tightly,  and  the  lip  of  the  os  uteri  is  not  cedematous 
from  the  pressure,  or  inflamed,  in  which  case,  it  is  better  to  trust  to 
the  natural  efforts.  The  operation  is,  to  gently  push  the  anterior  lip 
over  the  crown  of  the  head,  during  the  absence  of  a  pain,  and  retain 
it  there  by  firm  and  constant  pressure,  during  one  or  two  subsequent 
pains,  until  it  retracts  and  slips  over  the  head.  Not  unfrequently, 
this  operation  will  prove  unsuccessful,  and  the  continued  pressure  of 
the  finger  upon  the  lip  and  soft  parts,  will  cause  increased  swelling  and 
inflammation;  in  the  majority  of  cases  of  this  kind,  if  the  constriction 
of  the  lip  be  relieved  by  pressing  the  fetal  head  more  toward  the  pelvic 
cavity,  or  toward  the  sacrum,  and  holding  it  thus  during  a  few  pains, 
the  lip  will  retract  without  any  further  aid.  If  the  projecting  anterior 
lip  be  hypertrophied,  these  manipulations  will  prove  of  no  utility. 

Occasionally,  at  the  commencement  of  labor,  and  especially  in  cases 
where  the  fetal  head  is  very  small,  or  the  pelvis  uncommonly  large, 
the  os  uteri  may  descend  with  the  head,  as  far  as,  or  even  through,  the 
pelvic  outlet;  this  must  be  remedied  by  placing  the  patient  upon  her 
back,  with  the  shoulders  depressed,  and  the  hips  elevated — then  by 
gentle  and  steady  pressure  with  the  expanded  fingers,  return  the  pro- 
lapsed organ  to  its  proper  location. 

During  the  first  stage  of  labor,  the  principal  abnormal  condition  of 
the  parts  through  which  the  child  has  to  pass,  aside  from  actual  disease 
of  these  parts,  is  RIGIDITY  OF  THE  VAGINA  and  soft  parts  in  which  it 
may  become  necessary  to  employ  vaginal  injections,  or  to  apply  fomen- 
tations to  the  perineum.  A  warm  infusion  of  equal  parts  of  Elm  bark 


DIFFICULT    LABOR — FIRST    STAGE.  375 

and  Lobelia  may  be  used  in  injection;  and  the  same  articles  may  be 
used  as  a  cataplasm  or  fomentation  of  the  parts.  These,  however,  will 
not  always  be  required,  as  the  means  recommended  for  rigidity  of  the 
os  uteri  \vill  generally  likewise  overcome  the  rigidity  to  the  soft 
parts.  When  the  vagina  is  dry,  harsh,  and  hot,  Gelsemium  is  the 
indicated  remedy;  or  warm  Lard  Oil,  or  Lard  itself,  warmed  into 
a  state  of  fluidity,  may  be  injected  into  it  with  much  advantage;  but 
the  parts  should  never  be  anointed  by  friction. 

Among  the  causes  referable  to  the  child  or  its  envelopes,  certain 
conditions  of  the  membranes  may  be  named.  As  a  common  rule, 
when  the  os  uteri  becomes  fully  dilated,  the  membranes  are  ruptured 
by  the  internal  pressure  upon  them;  but  there  will  frequently  be 
found  exceptions  to  this  rule.  These  exceptions  are  owing  to:  1. — A 
RIGIDITY  OR  TOUGHNESS  OF  THE  MEMBEANES,  and 
which  render  the  labor  protracted,  by  retaining  the  liquor  amnii,  and 
thus  hindering  the  uterus  from  acting  with  energy,  after  the  os  has 
become  fully  dilated. 

TREATMENT. — In  cases  of  this  kind,  the  membranes  should  be 
ruptured  artificially,  after  which  the  contractions  will  become  stronger 
and  more  regular.  But  a  proper  degree  of  caution  is  required  before 
attempting  this  operation,  because,  if  prematurely  effected,  it  may 
terminate  in  more  serious  results  than  had  no  interference  taken  place. 
In  the  first  place,  there  should  be  good  ground  for  attributing  the 
delay  to  this  cause ;  secondly,  before  attempting  it,  the  os  uteri  should 
be  fully  dilated  and  the  soft  parts  in  a  yielding  condition  ;  and  thirdly, 
with  primiparse,  it  should  always,  if  possible,  be  postponed  until  the 
first  stage  of  labor  is  wholly  completed.  Feeble  and  inefficient  con- 
tractions for  several  hours,  with  softness  and  dilatability  of  the  parts, 
and  the  labor  having  nearly  or  fully  terminated  its  first  stage,  are 
among  the  symptoms  indicating  an  artificial  rupture.  It  is  sometimes 
difficult  to  effect  a  rupture  of  the  membranes,  especially  when  the 
pains  are  feeble,  and  the  use  of  a  probe  or  sharpened  quill  has  been 
recommended;  but  we  must  be  careful  in  using  any  cutting  or  punctur- 
ing instrument  not  to  injure  the  soft  parts  of  the  mother,  nor  the 
presenting  parts  of  the  child.  I  have  always  succeeded  with  the 
finger  nail,  pressing  it  upon  the  membranes  during  the  pain,  and 
making  a  sawing  motion  with  it  from  before  backward,  or  from  side 
to  side,  and  continuing  it  until  the  liquor  amnii  escapes. 

2. — The  wedge-like  pressure  of  the  bag  of  waters  is  an  important 
mechanical  agent  in  the  relaxation  and  dilatation  of  the  cervix  and 
os;  but  when  the  MEMBRANES  HAVE  RUPTURED  PREMA- 


376  KING'S  ECLECTIC  OBSTETRICS. 

TURELY,  either  spontaneously  or  artificially,  this  bag  is  absent,  the 
fetal  head  then  presses  upon  the  os  uteri,  but  is  illy  adapted  to  aid  its 
dilatation,  and  the  result  is  a  tedious  and  painful  labor.      The  pre- 
mature rupture  may  be  owing  to  a  weakness  of  the  membranes,  to 
violence,  or  to  a  careless  examination,  and  which  last  is  perhaps  a 
more  frequent  occurrence  than  is  generally  imagined.    An  early  rupt- 
ure of  the  membranes  is  also  an  indication  of  a  preternatural  presenta- 
tion, and  whenever  it  occurs  the  character  of  the  presentation  should 
be  determined  as  soon  as  possible,  that  timely  measures  may  be  adopt- 
ed, if  required.     When  the  membranes  are  prematurely  ruptured,  the 
liquor  amnii  may  be  discharged  in  a  very  short  time,  or  if  the  rent  be 
small,  or  the  fetal  head  lies  over  its  orifice,  this  fluid  may  slowly 
dribble  away,  and  add  much  to  the  discomfort  of  the  patient. 

TREATMENT. — If  the  as  uteri  is  dilatable,  and  the  pains  are 
.active,  nothing  is  required  but  a  little  patience,  as  the  labor  will 
usually  proceed  with  safety  to  both  mother  and  child.  If,  however, 
the  os  uteri  be  rigid  and  unyielding,  this  condition  must  be  overcome 
by  the  means  already  mentioned.  If  the  liquor  amnii  passes  off  slowly, 
the  os  being  dilatable,  and  the  pains  feeble,  the  orifice  in  the  mem- 
branes should  be  enlarged,  and  the  fetal  head  elevated,  between  the 
pains,  toward  the  sacrum,  in  order  to  admit  of  a  free  discharge  of  the 
liquor,  and  which  will  be  followed  by  active  contractions.  The  dila- 
tability  of  the  os  may  be  increased  by  Lobelia  or  Gelsemium  admin- 
istered internally,  or  by  a  rectal  enema  of  the  compound  tincture  of 
Lobelia  and  Capsicum. 

In  closing  this  chapter  on  the  causes  which  may  protract  the  first 
stage  of  labor,  I  desire  to  impress  upon  the  mind  of  the  student  that 
the  mere  fact  of  the  tediousness  of  this  stage  does  not  justify  any 
attempts  to  hasten  the  labor.  Delay  in  this  stage  seldom  causes  any 
serious  accident  to  either  the  mother  or  child,  unless,  from  a  want  of 
patience  and  prudence,  it  be  unnecessarily  or  improperly  interfered 
with.  True,  the  female  may  become  worn  out  or  exhausted,  but  this 
is  soon  removed  by  an  energetic  uterine  action  in  the  second  stage, 
and  in  which  stage  only  is  the  shock  given  to  the  nervous  .system 
which  may  produce  unpleasant  or  serious  results.  He  should,  there- 
fore, be  very  cautious  and  particular  in  ascertaining  that  artificial 
assistance  is  positively  required,  before  attempting  to  render  it; 
always  bearing  in  mind  the  wholesome  and  oft-repeated  saying  of 
Blundell,  that  " a  meddlesome  midwifery  is  bad"  No  interference  of 
any  kind  must  be  undertaken,  unless  it  be  desired  to  produce  certain 
results  or  conditions  favorable  to  a  safe  labor,  and  which  results  or. 
conditions  we  know  are  absolutely  indicated,  or  required. 


DIFFICULT    LABOR — SECOND    STAGE.  377 

CHAPTER    XXX. 

DIFFICULT    LABOR — SECOND    STAGE.. 

THE  SECOND  STAGE  OF  LABOR  may  be  protracted,  even 
when  the  first  has  progressed  favorably,  and  may  be  owing  to  causes 
not  necessarily  nor  immediately  connected  with  the  first  stage,  or  which, 
although  present  in  that  stage,  can  not  be  determined  until  the  com- 
plete dilatation  of  the  os  uteri,  and  which  causes,  I  shall  consequently 
consider  under  this  head. 

As  before  remarked,  although  labor  may  be  delayed  for  a  long  time 
during  its  first  stage,  without  any  hazard  to  the  mother  or  child,  yet 
such  is  not  the  case  in  the  second  stage,  for  any  procrastination  beyond 
a  certain  period  is  fraught  with  serious  consequences  to  both,  hence, 
the  accoucheur  should  allow  no  more  delay  in  the  labor  than  is  abso- 
lutely necessary,  but  should  promptly  and  skilfully  employ  all  measures 
for  facilitating  this  stage  of  the  labor,  that  are  compatible  with  the 
health  and  safety  of  the  woman ;  to  allow  her  to  suffer  unnecessarily 
from  a  tedious,  lingering  labor,  is  to  say  the  least  of  it,  a  very  cen- 
surable course.  The  development  of  bad  symptoms  may  not  take 
place  for  some  hours  after  the  commencement  of  the  second  stage,  or 
they  may  occur  within  six  or  eight  hours ;  and,  as  a  general  rule,  if 
this  stage  of  labor  has  continued  for  twelve  or  fifteen  hours,  symptoms  of 
constitutional  suffering  will  manifest  themselves.  The  pains,  after  hav- 
ing continued  regular  and  forcible  for  a  time,  gradually  become  more 
and  more  feeble,  occurring  at  less  regular  intervals,  and  causing  little 
or  no  advance  of  the  head.  They  may  return  only  at  long  intervals. 
or  the  intervals  may  be  alternately  short  and  long,  or  they  may  be 
regular,  the  pains  gradually  diminishing  in  force,  until  they  are  scarcely 
felt.  Or,  the  pains  may  commence  each  time  of  their  occurrence,  with 
energy,  but  subside,  almost  suddenly,  before  they  have  reached  their 
maximum  development ;  or  they  may  cease  entirely. 

This  impaired  condition  of  uterine  action,  is  very  frequently  accom- 
panied with  several  unpleasant  symptoms,  varying  in  degree  :  as  severe 
shiverings,  frequently  resembling  light  convulsive  attacks;  distressing 
and  frequent  vomitings,  of  green,  or  bilious  matter  ;  restlessness  and 
uneasiness  of  the  patient ;  the  skin  may  be  dry  or  moist,  but  in  either 
case  it  is  hot;  increase  of  pulse,  ranging  from  100  to  140;  the  tongue 
dry  and  furred,  with  sordes  about  the  teeth ;  the  mind  despondent, 
disturbed,  and  fearful ;  the  vagina  hot,  and  with  the  os  uteri,  tender 


378  KING'S  KCLKCTK    OHSTKTRIO. 

to  the  touch ;  the  mucous  discharge  from  the  vagina  becomes  brown  or 
yellowish,  and  occasionally  fetid  or  acrid;  and  urination  is  rendered 
difficult,  or  altogether  prevented  by  the  pressure  of  the  fetal  head. 
These  symptoms  usually  occur  in  the  order  just  given,  and  in  all  cases 
of  prolonged  second  stage,  some  of  them  will  be  present.  If  relief 
be  not  afforded,  they  increase  in  severity ;  the  vomiting  occurs  more 
frequently,  with  ejection  of  dark-colored  matters ;  restlessness  increases, 
with  obstinate  hiccough ;  the  abdomen  becomes  tender ;  the  skin  cov- 
ered with  a  cold,  clammy  sweat;  the  pulse  rapid  and  feeble;  the 
tongue  dry  and  brown  ;  stupor  and  low-muttering  delirium  ensues,  and 
death  terminates  the  scene.  Not  only  is  the  life  of  the  mother  endan- 
gered in  such  cases,  but  also  that  of  the  child,  by  the  delay  of  proper 
interference. 

The  causes  of  difficult  labor  in  its  second  stage  may  be  referred  to  :  1, 
the  uterus ;  2,  to  the  parts  or  passages  through  which  the  child  passes  ; 
3,  to  abnormal  conditions  of  neighboring  organs;  4,  to  the  child. 

1. — Among  those  attributable  to  the  conditions  of  the  uterus, 
one  of  the  most  common  causes  of  delay  in  the  second  stage,  is  a 
CESSATION,  OR  INEFFICIENCY  OF  THE  UTERINE  CON- 
TRACTIONS. As  may  have  been  observed  in  the  previous  chapter, 
this  is  also  a  cause  of  prolonged  first  stage,  but  its  effects  are  by  no 
means  so  grave  in  that  stage.  It  may  be  owing  to  disease,  sudden  and 
violent  emotions  of  the  mind,  tumors,  constitutional  debility,  etc. 
Females  of  an  irritable,  nervous  temperament,  may  have  labor  pro- 
tracted, during  its  second  stage,  from  this  cause ;  and  those  of  debili- 
tated constitution,  frequently  have  a  failure  of  uterine  action  in  this 
stage,  and  especially,  when  from  prolongation  of  the  first  stage,  great 
exhaustion  occurs. 

TREATMENT.— When  attending  a  case  in  which  the  action  of 
the  uterus  becomes  lessened,  the  pains  short  and  inefficient,  or  at  long 
intervals,  with  no  advance  of  the  fetal  head ;  increased  and  irregular 
pulse,  restlessness,  anxiety,  and  wakefuLness  being  also  present,  it  will 
become  necessary  for  the  practitioner  to  institute  a  very  minute  and 
careful  examination  not  only  of  the  genital  organs,  but  likewise  of  the 
condition  of  the  tongue,  pulse,  skin,  head,  and  abdomen.  By  the 
examination  of  the  genital  organs  he  will  ascertain,  if  possible,  the 
cause  of  the  delay,  and  determine  by  it  the  best  method  of  affording 
assistance ;  and  by  the  condition  of  these  parts,  in  connection  with 
the  general  condition  of  the  system,  he  will  be  guided  as  to  the  proper 
time  for  interference. 


DIFFICULT    LABOR — SECOND    STAGE.  379 

The  cause  of  the  delay  can,  of  course,  be  learned  only  from  the 
examination.  The  best  method  of  affording  assistance,  is,  invariably, 
that  which  readily  and  most  easily  terminates  the  labor,  and  with  the 
least  danger  to  the  mother  and  child,  and  which  must  vary  according  to 
the  causes  and  conditions  present.  Among  these  means  may  be  named, 
Ergot,  Sulphate  of  Quinia,  Macrotys,  etc.,  the  Vectis,  the  Forceps,  and 
the  Crotchet ;  each  of  which  will  be  considered  hereafter.  The  proper 
time  for  interference,  will  depend  entirely  upon  the  symptoms;  an  in- 
crease of  the  pulse,  febrile  symptoms,  soreness  and  tension  of  the 
abdomen ;  exhaustion ;  watchfulness,  and  anxiety ;  a  dry,  hot,  puffy, 
or  swollen  condition  of  the  soft  parts,  caused  by  the  long-continued 
pressure  and  interrupted  circulation,  and  accompanied  with  a  degree 
of  tenderness  which  renders  a  vaginal  examination  painful ;  a  retention 
of  urine,  from  pressure  of  the  fetal  head  on  the  urethra  and  neck  of 
the  bladder,  requiring  the  use  of  the  catheter,  which  can  be  introduced 
only  with  difficulty ;  and  a  change  in  the  character  of  the  vaginal 
discharges,  they  becoming  offensive — are  all  symptoms  requiring  im- 
mediate delivery.  Indeed,  as  a  general  rule,  it  is  good  practice  to 
interfere,  even  before  the  local  symptoms  have  appeared. 

If,  in  cases  of  protracted  labor  from  rigidity,  the*  constitutional  dis- 
turbance is  excessive,  with  exhaustion  of  the  vital  forces,  and  determi- 
nation of  blood  to  particular  organs,  especially  the  brain,  the  prognosis 
is  very  unfavorable.  Fever,  in  either  stage  of  labor,  manifested  by 
chills,  increased  pulse,  furred  tongue,  and  flushed  countenance,  indi- 
cates the  want  of  artificial  aid;  and  the  case  assumes  a  still  more 
serious  aspect,  if  the  pains  gradually  lessen  in  frequency  and  power, 
the  fetal  head  ceasing  to  advance,  and  the  female  becoming  exhausted. 
Sometimes,  these  symptoms  come  on  very  suddenly,  requiring  an 
immediate  interference ;  the  pains  cease,  the  mind  becomes  confused 
and  wandering,  a  clammy  perspiration  covers  the  face  and  body,  rest- 
lessness with  constant  hiccough  occurs,  and  the  patient  becomes  so 
completely  changed  in  features  and  in  tone  of  voice,  as  to  be  hardly 
recognized  by  her  friends.  These  symptoms  may  occur  during  the 
first  stage,  but  they  will  be  more  frequently  met  with  in  the  second 
stage,  where  the  head  has  passed  through  the  os  uteri  into  the  pelvic 
cavity,  and  has  been  pressing  for  a  considerable  time  upon  the  parts  at 
the  inferior  strait. 

It  is  frequently  the  case  that  the  contractile  power  of  the  uterus  is 
BO  readily  exhausted,  that  after  having  effected  the  first  stage  of  labor, 
the  pains  cease,  or  become  very  feeble  in  the  second.  In  these 
instances  the  pelvic  diameters  will  be  sufficiently  ample,  the  soft  parts 


380  KING'S    ECLECTIC    OBSTETRICS. 

in  a  yielding  condition,  and  the  head,  in  whatever  portion  of  the 
cavity  it  may  be,  will  be  found  in  a  normal  position.  In  such  cases, 
and  under  such  circumstances,  the  labor  may  be  readily  terminated 
by  applying  the  forceps,  but  if  it  seems  that  the  case  needs  no  instru- 
mental interference,  but  will  probably  result  within  a  short  time  in 
natural  delivery,  Macrotys  should  be  administered,  in  the  usual 
small  dose,  every  fifteen  or  thirty  minutes;  and  if  this  fails,  and 
symptoms  of  exhaustion  manifest  themselves,  it  will  then  be  proper  to 
administer  Ergot,  or  apply  the  forceps  and  deliver  at  once;  or  if 
having  administered  Ergot  and  it  fails,  within  a  reasonable  time,  to 
stimulate  the  uterus  to  action,  resort  to  the  forceps  without  further 
delay.  And,  indeed,  this  course  may  be  pursued  in  all  cases  of  ineffi- 
cient uterine  contraction,  owing  to  mere  debility  or  exhaustion  of  the 
organ.  Notwithstanding  that  Ergot  has  been  so  frequently  employed 
to  facilitate  labor,  with  no  apparent  immediate  pernicious  results,  yet 
the  practitioner  should  ever  bear  in  mind  that  it  is  a  dangerous  rem- 
edy at  best,  requiring  much  judgment  and  discrimination  in  its  em- 
ployment. The  dangers  attending  its  use  to  the  mother  are,  rupture 
of  the  uterus,  rupture  of  the  perineum,  inversion  of  the  uterus,  etc., 
to  the  child  death, -and  more  certainly  if  the  cord  is  around  its  neck. 
And,  although  it  has  been  employed  with  impunity  in  many  cases, 
where  the  only  indication  for  its  use  was  the  impatience  of  the  practi- 
tioner— a  regard  to  his  owrn  comfort  and  feelings,  in  preference  to  the 
safety  of  his  patient — still,  it  is  an  agent  whose  action  is  always  to  be 
dreaded;  and  the  success  attending  its  administration  in  the  instances 
just  referred  to  have  been  the  results  of  good  luck,  and  not  of  any 
superior  skill  or  wisdom  of  its  prescribers. 

Ergot  has,  undoubtedly,  a  specific  action  upon  the  uterus,  which 
usually  commences  within  twenty  or  thirty  minutes  after  its  exhibi- 
tion ;  and  the  character  of  the  contractions  produced  by  it  are  mate- 
rially different  from  those  of  natural  labor.  They  are  stronger  and 
of  longer  duration,  resembling  a  number  of  violent  or  spasmodic 
uterine  contractions  continued  into  one  another  without  intervals. 
During  a  contraction,  the  circulation  of  the  maternal  blood  in  the 
uterus  and  placenta  must  be  interrupted;  and  when  this  interruption 
occurs  for  a  long  continued  time,  as  when  effected  by  ergotic  influence, 
preventing  the  necessary  changes  in  the  fetal  blood,  we  should  anti^ 
cipate  unfavorable  results  to  the  child,  and  not  be  unexpectedly 
astonished  upon  finding  it  born  in  an  asphyxiated  condition. 

As  it  is  not  uncommon  to  meet  with  individuals  whose  constitutions 
are  insusceptible  to  the  specific  influences  of  one  or  more  drills,  go 


DIFFICULT    L  \IJOR — SKCOND    STAGE.  381 

must  we  expect  to  meet  with  females  upon  whom  Ergot  exerts  but 
little  or  none  of  its  peculiar  action;  and  this  want  of  susceptibility 
may  account  for  many  of  the  failures  which  have  been  recorded  by 
authors.  Another  cause  of  failure  has  been,  undoubtedly,  the  want 
of  a  recent  article;  for  an  inferior  preparation  of  Ergot,  often 
found  on  the  market,  does  not  possess  the  property  of  exciting 
uterine  action,  and,  no  matter  how  carefully  it  may  be  admin- 
istered, it  being  a  worthless  article,  failure  will  follow.  One  of  the 
best  and  most  reliable  preparations  is  Lloyd's  Ergot,  the  usual  dose 
of  which  is  from  thirty  to  sixty  drops.  This  preparation  has  the  ad- 
vantage over  others,  in  that  it  may  be  used  hypodermically,  being 
free  from  Alcohol.  In  extreme  cases  it  should  be  used  in  this  way, 
by  means  of  the  ordinary  hypodermic  syringe,  the  dose  being  from 
five  to  twenty  drops,  repeated  if  necessary,  governed  by  the  effect 
produced.  As  constipation,  or  a  disordered  condition  of  the  digestive 
organs,  is  frequently  a  cause  of  deficient  uterine  action,  the  practi- 
tioner should  never  administer  Ergot  without  having  first  unloaded 
the  bowels  by  enema,  or  by  the  administration  of  a  mild  laxative. 

In  the  administration  of  Ergot  to  females  during  parturition, 'there 
are  certain  rules  to  be  guided  by,  which  are  based  upon  the  recorded 
experience  and  observation  of  many  medical  men,  and  which  should 
.be  thoroughly  impressed  upon  the  mind  of  every  individual  who  at- 
tempts the  conduct  of  a  labor;  they  are,  briefly,  as  follows: 

Ergot  should  never  be  given  for  the  relief  or  comfort  of  the  practi- 
tioner; where  any  deformity  of  the  pelvis  is  suspected;  where  the 
head  is  suspected  to  be  disproportionately  large;  where  the  presenta- 
tion is  beyond  reach,  or  can  not  be  determined;  wlrere  there  exists 
an  obstruction  in  the  soft  parts,  as  rigidity,  etc.;  where  there  is  a 
malpresentation ;  where  there  exists  increased  excitement  of  the 
nervous  or  vascular  system ;  .  where  there  is  a  tendency  to  cerebral 
symptoms ;  afld  wrhere  the  os  uteri  is  not  fully  dilated.  It  should  never 
be  given  while  the  woman's  strength  is  greatly  exhausted,  lest  the  ex- 
haustion produced  by  it  be  more  excessive  than  her  system  can  bear. 

Ergot  should  be  avoided,  as  much  as  possible,  in  first  labors,  lest 
rupture  of  the  perineum  ensue. 

Ergot  may  be  given,  ix  CAREFUL  HANDS,  in  multiparse,  where  the 
sole  cause  of  delay  is  deficient  uterine  contraction;  where  the  head 
presents  and  is  low  in  the  pelvis,  the  os  uteri  soft  and  fully  dilated, 
the  soft  parts  yielding  and  dilatable,  and  the  membranes  have  rup- 
tured ;  and  the  pelvis  must  be  ample,  with  normal  proportions  be- 
tween it  and  the  fetal  head.  The  patient  must  also  be  somewhat 


382  KING'S  ECLECTIC  OBSTETRICS. 

exhausted,  but  without  any  symptoms  of  fever  or  inflammation;  I 
must  confess,  however,  that  I  prefer  not  to  wait  for  any  considerable 
degree  of  exhaustion  before  administering  this  article. 

Some  authors  recommend  the  administration  of  twenty  or  thirty 
grains  of  Ergot  in  powder,  or  infusion,  for  a  single  dose;  but  in  my 
own  practice,  in  all  cases  where  I  have  considered  its  use  indicated 
and  advisable,  I  have  succeeded  in  arousing  the  contractions  of  the 
uterus,  in  fifteen  or  thirty  minutes,  by  the  use  of  one  of  the  fluid  prep- 
arations, either  a  reliable  fluid  extract  or  the  specific  tincture;  my 
preference,  however,  is  the  article  previously  mentioned,  and  known 
as  Lloyd's  Ergot,  in  half  to  one  drachm  doses. 

I  would  remark  here,  however,  that  among  those  practitioners  who 
are  acquainted  with  the  parturient  virtues  of  Macrotys,  the  employ- 
ment of  Ergot  for  the  purpose  of  inducing  (spasmodic)  contractions 
of  the  uterus,  is  not  so  often  required.  .  It  might  be  well,  in  the  cases 
under  consideration,  to  give  this  agent  a  fair  trial  before  resorting  to 
the  ergotic  preparations;  more  especially  as  it  may  be  exhibited  with 
greater  safety,  and  at  an  earlier  period  of  labor ;  beside,  the  contrac- 
tions induced  bear  a  greater  resemblance  to  those  caused  solely  by  the 
natural  powers. 

It  will  sometimes  be  found  that,  although  the  contractions  of  the 
uterus  may  be  aroused  by  the  administration  of  Ergot,  they  are  not 
of  an  expulsive  character;  in  such  cases  the  uterus  contracts  firmly 
upon  the  part  of  the  child  within  it,  preventing  its  advance,  and  caus- 
ing its  death  by  the  pressure  maintained  around  it,  unless  timely 
assistance  be  afforded  by  the  employment  of  the  forceps.  Hence,  it  is 
recommended  by  our  best  accoucheurs  to  have  a  forceps  at  hand  when 
this  drug  is  exhibited.  It  must  be  recollected,  however,  that  so  long 
as  the  pains  continue,  with  an  advance  of  the  head,  however  slowly,  the 
pulse  continuing  good,  no  trouble  in  urinating,  and  no  pain  of  the 
abdomen  on  pressure,  ARTIFICIAL  INTERFERENCE  is  NOT  REQUIRED; 
but  in  debilitated  patients,  in  whom  symptoms  of  exhaustion  and 
fever  appear,  interference  will  be  demanded,  even  though  the  head  be 
very  slowly  advancing.  And  by  delaying  the  necessary  aid,  the 
patient  may  die  after  delivery,  from  the  shock  of  the  labor,  or  from 
hemorrhage  and  retained  placenta,  or,  should  life  be  spared,  sloughing 
of  the  uterus,  vagina,  bladder,  and  rectum  may  take  place,  rendering 
her  subsequent  existence  painful  and  burdensome  in  the  extreme. 

I  have  known  Sulphate  of  Quiuia,  in  a  dose  of  three  to  five  grains, 
to  increase  the  expulsive  action  of  the  uterus  in  several  instances,  in 


DIFFICULT    LABOR SECOND    STAGE.  383 

which  this  action  was  inefficient ;  and  yet  a  large  numoer  of  practi- 
tioners have  denied  that  it  possesses  such  influence.  In  the  cases 
under  consideration,  where  the  diminution  of  uterine  action  has  no 
other  cause  than  general  or  local  debility,  Crede's  operation  has  been 
successfully  employed.  The  woman  being  placed  on  her  back,  the 
accoucheur  applies  the  palmar  surface  of  his  open  hands  upon  the  ab- 
dominal walls,  immediately  over  the  fundus  and  sides  of  the  uterus, 
and,  as  soon  as  a  pain  commences,  he  makes  firm  pressure  downward 
and  in  the  direction  of  the  axis  of  the  superior  strait,  ceasing  his 
efforts  with  the  cessation  of  the  pain  and  repeating  them  as  soon  as  it 
recommences,  and  so  on,  until  the  head  is  born.  This  operation  should 
not  be  practiced  with  violence  or  rudeness,  and  can  only  prove  ser- 
viceable in  cases  of  normal  vertex  presentation,  and  where  the  mater- 
nal pelvic  diameters  are  sufficiently  large.  It  increases  the  strength 
as  well  as  the  duration  of  the  pains. 

2.— PRECIPITATE  LABOR  may  be  due  to  violent  or  excessive 
action  of  the  uterus,  to  great  relaxation  of  the  maternal  tissues,  to  an 
abnormally  large  pelvis,  to  premature  rupture  of  the  membranes,  or  to 
the  child  being  quite  small.  AVomen  who  are  subject  to  dysmenorrhea, 
or  who  are  well  developed  muscularly  but  at  the  same  time  excessively 
nervous,  are  liable  to  powerful  uterine  action ;  sometimes  it  appears 
to  be  hereditary.  Occasionally  ovarian  excitement,  mental  excitement 
of  any  kind,  and  even  hysteria,  will  give  rise  to  an  increase  of  the 
labor  paiu»  in  the  second  stage.  The  dangers  of  such  increased  and 
hurried  action  of  the  uterus  are,  injury  to  the  child,  rupture  of  the 
cord,  sudden  detachment  of  the  placenta  followed  by  dangerous  hem- 
orrhage, inversion  of  the  uterus,  rupture  of  the  uterus,  vagina,  and 
perineum,  and  syncope,  etc.;  and  from  the  continuous  and  forcible 
straining  of  the  wToman,  not  unfrequently,  subcutaneous  emphysema 
of  the  neck  and  head,  as  well  as  more  or  less  cerebral  disturbance.  If 
the  practitioner  is  present  at  the  time  of  this  violent  action,  he  must 
promptly  employ  means  to  palliate  according  to  the  cause.  The  woman 
must  be  kept  constantly  in  the  recumbent  position, 'and,  to  lessen  ex- 
cessive uterine  action,  opiates,  Gelsemium,  compound  tincture  of 
Lobelia  and  Capsicum,  Chloral-hydrate,  Bromide  of  Potassium,  or 
Chloroform,  etc.,  may  be  used  in  full  doses.  All  stimulus  must  be 
avoided ;  unnecessary  examinations  must  be  dispensed  with ;  the 
bowels  should  be  opened  by  laxative  enema,  followed  subsequently  by 
sedative;  and  the  woman  should  not  be  allowed  to  bear  down,  but 


384  KING'S  ECLECTIC  OBSTETRICS. 

rather  encouraged  to  cry  out  loudly.  When  the  pelvis  is  large,  or  the 
head  of  the  child  small,  the  methods  named  under  Abnormally  Large 
Pelvis  may  be  pursued. 

3. — Very  rarely,  the  labor  is  interfered  with  by  an  IMPERFO- 
RATE  OS  UTERI,  which  may  be  suspected  when  .the  pains  are  reg- 
ular, increasing  gradually  in  force,  pushing  the  lower  segment  of  the 
uterus  into  the  cavity  of  the  pelvis,  rendering  it  very  thin,  without  any 
opening  of  the  os  uteri  being  discoverable. 

There  may  be  an  Agglutination  of  the  Os  Uteri,  the  result  of  some 
previous  inflammation  of  the  part,  and  which  may  be  detected  by 
finding  an  indentation,  or  depressed  fold  at  the  center  of  the  os  uteri, 
without  any  opening;  the  pains  will  be  regular,  increasing  gradually 
in  force,  pushing  the  lower  segment  of  the  uterus  into  the  cavity  of 
the  pelvis,  rendering  it  extremely  thin ;  or  the  Os  Uteri  may  be  oblit- 
erated. These  conditions  are,  however,  rarely  met  with. 

TREATMENT. — It  may  be  that  the  os  uteri  is  merely  rigid  and 
not  dilatable,  and  the  means  recommended  for  this  difficulty  may  be 
pursued,  whenever  the  os  can  be  discovered.  Sometimes  the  os  uteri 
is  closed  by  agglutination,  resisting  the  most  powerful  uterine  con- 
tractions; in  such  instances,  Dr.  Rigby  remarks,  "A  moderate  degree 
of  pressure  against  it  while  in  a  state  of  strong  distension,  either  by 
the  tip  of  the  finger  or  a  female  catheter,  is  quite  sufficient  to  over- 
come it;  little  or  no  pain  is  produced,  and  the  appearance  of  a  slight 
discharge  of  blood  will  show  that  the  stricture  has  given  away." 

If  no  opening,  however,  can  be  found,  it  will  become  necessary  to 
divide  the  presenting  wall  of  the  uterus,  and  form  an  artificial  os 
uteri,  through  which  the  child  may  pass.  A  crucial  incision  is  to  be 
made  upon  the  anterior-inferior  part  of  the  wall,  as  near  the  situation 
of  the  os  uteri  as  possible,  by  means  of  a  sharp-pointed  bistoury;  this 
knife  is  carefully  passed  along  the  left  forefinger  as  a  guide,  and  must 
not  be  pushed  too  deeply  into  the  uterine  wall,  lest  the  presenting 
part  of  the  fetus  be  injured.  In  performing  the  antero-posterior  in- 
cision, care  must  be  taken  not  to  extend  it  so  far,  either  forward  or 
backward,  as  to  injure  the  bladder  or  rectum.  After  the  operation, 
the  delivery  may  be  left  to  the  natural  efforts. 

It  must  be  recollected,  however,  that  it  is  frequently  the  case  that 
from  uterine  anterior  obliquity  the  os  uteri  will  be  higher  up,  perhaps 
entirely  beyond  the  reach  of  the  finger,  and  looking  toward  the  prom- 
ontory of  the  sacrum,  and  in  which  position  it  may  remain  for  several 


DIFFICULT   LABOR — SECOND   STAGE.  385 

hours,  retarding  the  progress  of  the  labor,  and  a  careful  search  should 
always  be  instituted  previous  to  attempting  any  operation.  If  it  be 
found  thus  elevated  and  inclined,  the  labor  may  be  expedited  by 
drawing  it  downward  and  forward  with  one  or  two  fingers,  in  the 
direction  of  the  axis  of  the  superior  strait,  and  holding  it  there  until 
the  engagement  of  the  head  will  prevent  a  return  to  its  former  in- 
clination. 

Sometimes  the  orifice  of  the  os  uteri  will  be  found  so  minute  or 
contracted,  from  disease  or  other  causes,  that  the  head  can  not  pass 
through  it,  even  when  dilated ;  for  which  the  same  course  must  be 
pursued  as  named  for  cancer  of  the  os  uteri,  being  careful  in  all  opera- 
tions not  to  carry  the  incisions  into  the  rectum  or  bladder. 

I  would  remark  here,  that  some  of  these  latter  conditions,  existing 
as  causes  of  difficult  labor,  may  be  found  present  in  the  first  stage  of 
labor,  when  they  should  be  as » promptly  attended  to  as  the  circum- 
stances of  the  case  will  permit ;  preparing  the  parts,  if  possible,  so 
that  no  delay  may  take  place  during  the  second  stage. 

3.— FIBROUS  TUMORS  of  the  CERVIX  UTERI,  are  occa- 
sionally met  with,  instances  of  which  are  recorded,  where  the  labors 
were  finished  without  more  than  ordinary  assistance,  the  mothers 
recovering,  but  the  children  being  still-born.  In  such  cases  it  is  bet- 
ter to  delay  all  operations,  if  there  is  the  least  possibility  of  the  deliv- 
ery being  effected  by  the  natural  powers;  but  when  this  is  impossible, 
from  the  excessive  size  of  the  tumor,  from  the  want  of  proper  uterine 
contractions,  or  from  exhaustion  of  the  mother,  the  child  will  have  to 
be  extracted  by  means  of  embryotomy,  or,  if  this  be  impracticable,  by 
the  Cesarean  operation. 

4. — A  POLYPUS  may  arise  from  the  body  or  neck  of  the  uterus, 
or  it  may  be  adherent  to  the  walls  of  the  vagina,  and  in  either  case 
present  an  obstacle  to  the  delivery.  It  may  be  known  by  its  firm, 
fleshy  feel,  its  movability,  its  pear-shape,  and  its  long,  narrow  neck ; 
during  labor  it  has  sometimes  been  mistaken  for  the  child's  he;>d. 

TREATMENT. — If  the  tumor  be  detected  at  an  early  period  of 
labor,  it  m'ight  be  prevented  from  descending,  by  pressing  it  back 
during  the  absence  of  a  pain,  and  holding  it  thus  until  the  head  has 
passed  beyond  it;  but  this  is  not  practicable  in  all  instances,  and 
especially  when  the  tumor  is  very  large.  In  every  case  of  this  kind 
it  will  be  proper  to  trust,  for  a  time,  to  the  resources  of  nature ;  but 
25 


386  KING'S  ECLECTIC  OBSTETRICS. 

when  the  parts  become  hot,  dry,  and  swollen,  and  the  uterine  efforts 
inefficient,  interference  is  required,  for  a  too  protracted  delay  is 
hazardous  to  both  mother  and  child.  The  only  operation  necessary 
is  the  removal  of  the  tumor  by  excision,  and  not. perforation  of  the 
child's  skull ;  for  the  danger  from  hemorrhage  after  the  operation  is 
not  so  great  as  to  justify  the  destruction  of  the  child.  "The  polypus 
should  be  drawn  down  as  much  as  "possible  by  a  forceps  proper  for  the 
purpose,  a  temporary  ligature  applied,  and  the  stem  cut  through." 
"  It  is  not  likely  that  the  ovum  could  be  brought  to  maturity,  if  a 
large  polypus  occupied  the  cavity  of  the  uterus;  it  is  therefore  fair  to 
assume,  that  when  a  polypus  is  found  to  impede  parturition,  it  must 
be  attached  to  the  mouth  of  the  uterus,  and  therefore  it  can  be  the 
more  easily  traced  to  its  origin,  so  that  you  have  every  facility  to 
assist  your  diagnosis." — (Murphy.)  If  the  presence  of  a  polypus  in 
the  pelvic  canal  be  discovered  during  the  latter  period  of  utero-gesta- 
tiou,  and  its  size  be  such  as  to  possibly  render  labor  protracted  and 
difficult,  it  should  at  once  be  ligated  and  excised,  or  it  may  be 
removed  by  the  ecraseur,  when  this  can  be  done. 

5. — Other  tumors  may  be  present  as  impediments  to  the  progress 
of  labor,  as  FUNGOUS,  or  CAULIFLOWER  TUMORS,  which, 
from  their  spongy  character  and  tendency  to  hemorrhage,  may  be  mis- 
taken for  a  placenta  prsevia ;  these  may  spring  from,  either  lip  of  the 
cervix,  and  when  small  may  allow  the  birth  of  the  child  without  any 
artificial  aid,  but  when  large  they  may  have  to  be  incised,  or  entirely 
removed  by  excision;  iu  either'case,  there  will  be  but  a  slight  chance 
for  the  mother's  recovery.  Embryotomy  and  gastrotomy  have  both 
been  performed  in  these  cases,  but  generally  with  fatal  results. 

Among  the  causes  due  to  the  condition  of  the  passages  through 
which  the  child  passes,  are:  1.— RIGIDITY  OF  THE  SOFT 
PARTS,  especially  of  the  perineum.  In  such  cases  a  resort  to  Ergot, 
•or  the  forceps,  while  the  rigidity  remains,  is  highly  censurable.  Oc- 
casionally, during  the  advance  of  the  fetal  head,  the  os  uteri,  instead 
of  yielding,  grasps  the  head  during  each  pain,  and  prevents  its  further 
progress;  this  is  apt  to  alarm  the  practitioner,  who,  having  ascer- 
tained that  the  position  of  the  head  is  correct,  finds  it  to  remain  sta- 
tionary, notwithstanding  pain  after  pain  continues  with  much  force  and 
severity.  A  careful  examination,  as  to  the  presentation  and  position 
of  the  head,  and  its  relative  proportions  with  the  pelvic  diameters, 


DIFFICULT    LABOR SECOND    STAGE.  387 

in  >y  determine  the  cause  of  the  delay.     -The  same  cause  frequently 
prevents  the  head  from  rotating. 

TREATMENT. — Patience  is  required  in  these  cases,  in  conjunction 
with  the  means  named  for  overcoming  rigidity  in  the  previous  chap- 
ter. In  the  instance  of  rigid  os  delaying  the  advance  of  the  fetal 
head,  it  will  always  be  proper  to  correct  any  abnormal  position  of  the 
uterus  which  may  be  present,  so  that  its  longitudinal  axis  may  corres- 
pond with  the  axis  of  the  superior  strait. 

The  following  abstract  is  taken  from  Braithwaite' s  Retrospect : 
"Dr.  Washington  has  recently  discovered  that  dry-cupping,  applied 
to  the  lowest  part  of  the  sacrum,  produces  dilatation  of  the  os  uteri ; 
and,  applied  higher  up,  contraction  of  the  uterus.  In  a  case,  where 
the  pains  had  endured  fourteen  hours  without  producing  any  per- 
ceptible effect,  in  consequence  of  rigidity  of  the  os  uteri,  Dr.  Wash- 
ington applied  a  dry  cup  as  low  down  on  the  sacrum  as  possible,  so 
as  to  cover  the  origin  of  the  nerves  to  the  os  uteri.  Complete  relaxa- 
tion ensued;  at  the  next  pain,  the  head  descended  to  the  outlet;  and 
.at  the  second  pain  the  patient  was  safely  delivered ;  and  that  in  less 
than  ten  minutes  from  the  application  of  the  cups.  In  tedious  labor, 
the  cup  should  be  applied  first  to  the  lowest  point  of  the  sacrum,  and 
if,  in  the  course  of  ten  or  fifteen  minutes,  the  patient  is  not  delivered, 
another  should  be  applied  higher  up,  so  as  to  cause  the  uterus  to  con- 
tract. The  lower  one  should  always  be  on  when  the  upper  one  is  applied, 
so  as  to  insure  relaxation  of  the  os  uteri  when  the  pains  come  on. 

'  "In  retained  placenta,  the  cups  are  to  be  applied  higher  up,  so  as  to 
cause  the  uterus  to  contract  at  once,  the  relaxation  of  the  os  uteri 
being  always  sufficient  after  the  fetus  has  passed.  When  Ergot  is 
administered,  the  woman  is  delivered  by  main  force,  without  any 
relaxation  except  that  produced  by  the  most  fearful  pains.  By  dry- 
cupping,  two  or  three  pains  are  sufficient,  and  the  amount  of  suffering 
is  not  more  than  ordinary." 

2.— A  CICATEIX  IN  THE  VAGINA,  will  sometimes  be  met 
with,  which  will  present 'an  impediment  to  the  delivery;  it  is  usually 
the  result  of  sloughing  effected  in  a  previous  tedious  labor,  in  which, 
the  healing  of  the  ulcer  which  remains  after  the  separation  of  the, 
slough,  occasions  a  diminution  of  the  diameters  of  the  vaginal  canal. 
An  examination  will  detect,  at  some  portion  of  the  vaginal  wall,  a 
.firm,  unyielding  band,  which  may  occupy  from  three  to  six  lines 


388  KING'S  ECLECTIC  OBSTETRICS. 

longitudinally,  or  which  may  present  merely  a  very  thin  edge,  the 
thickness  of  a  water.  The  difficulty  will,  of  course,  be  proportioned 
to  the  firmness  and  extent  of  the  cicatrix,  and  is  always  a  serious  ob- 
stacle to  labor. 

TREATMENT. — In  thesv  cases  we  should  not  interfere  prema- 
turely, but  always  wait  and  learn  Avhat  the  natural  efforts  can  do; 
strong  and  energetic  contractions,  with  the  pressure  of  the  fetal  head, 
may  overcome  the  difficulty.  But  where  assistance  is  required,  relax- 
ation, effected  by  Lobelia  or  Gelsemium,  administered  by  mouth,  and 
by  rectal  enema  of  compound  tincture  of. Lobelia  and  Capsicum  will 
usually  produce  the  desired  dilatability,  and  the  head  will  advance 
without  any  further  delay.  Where  the  cicatrix  is  of  great  extent,  and 
very  firm  and  unyielding,  the  inhalation  of  Chloroform  will  in  some 
cases,  relax  the  parts  after  the  ordinary  internal  medication  has  failed; 
anasthesia  should  be  carried  to  the  extent  of  producing  complete  relax- 
ation. Occasionally  it  happens  that  the  cicatricial  bands  are  so  firm, 
that  to  induce  dilatation  more  radical  measures  must  be  resorted  to. 
It  is  advised  in  such  cases,  by  excellent  authority,  to  slightly  incise 
the  edges  of  the  constricted  part  in  three  or  four  places,  being  careful 
to  avoid  the  neck  of  the  bladder,  the  rectum,  and  the  two  uterine  ar- 
teries, which  pass  up  from  below  on  each  side  of  the  vagina;  and  for 
this  purpose  the  incisions  should  be  made  one  behind  each  groin,  and 
one  toward  each  sacro-iliac  symphysis.  The  least  snip  is  sufficient,  as 
the  advance  of  the  head  will  probably  widen  it.  After  the  delivery, 
a  sponge  or  bougie,  well  oiled,  should  be  introduced  into  the  canal 
and  changed  two  or  three  times  a  day,  so  that  as  the  part  heals,  the 
diameters  of  the  vagina  do  not  again  become  lessened.  The  artificial 
increase  of  the  vaginal  passage  by  incisions,  should  be  attempted  with 
great  care,  and  under  the  advice  of  counsel,  for,  however  slight  the 
operation  may  be,  the  advance  of  the  head  may  cause  the  cut  to  widen 
and  produce  a  much  more  extensive  laceration  than  if  the  case  had 
been  left  to  the  natural  powers.  Indeed,  I  am  somewhat  inclined  to 
believe  that  the  operation  will  very  rarely  be  found  necessary,  where 
the  previously-named  treatment  has  been  faithfully  pursued.  Some- 
times considerable  hemorrhage  follows,  and  cases  have  occasionally 
terminated  fatally.  If  the  contractions  of  the  uterus  become  inefficient, 
or  unfavorable  symptoms  present  themselves,  the  labor  may  demand 
a  prompt  termination  by  instruments,  the  use  of  which,  in  such  cases, 
even  with  the  greatest  care,  is  apt  to  produce  more  or  less  extensive 
lacerations,  and  which  are  not  without  danger;  and  a  knowledge  of 
this  fact  may  lead  to  the  practice  of  patience  and  caution. 


DIFFICULT    LABOR FROM    PELVIC    DEFORMITY.  389 

Where  the  practitioner  is  aware  of  this  difficulty  at  an  early  period 
during  gestation,  or  has  reasons  to  suspect  it,  it  is  proper  for  him  to 
explain  the  matter  to  his  patient,  and  request  an  examination,  when 
if  the  constriction  be  found  very  great,  he  may  induce  premature  labor, 
and  thereby  save  the  mother  the  hazards  that  she  would  run  at  full 
period ;  and  the  same  course  may  be  pursued  with  females  known  to 
be  laboring  under  Cancer  of  the  Os  Uteri.  In. this  latter  condition  of 
the  cervix,  at  ,full  term,  when  the  labor  is  delayed  thereby,  it  may 
become  necessary  to  divide  the  diseased  part  sufficiently  to  admit  the 
passage  of  the  child.  But,  as  this  operation  is  only  to  be 'attempted 
for  the  child's  safety,  we  must  be  certain  that  it  is  alive  before  per- 
forming it ;  the  death  of  the  mother  is  to  be  expected  in  such  cases, 
no  matter  what  course  is  pursued.  Cauliflower  Excrescence  may  be 
similarly  managed. 

3.— IMPERFORATE  or  UNRUPTURED  HYMEN,  may  pre- 
vent the  passage  of  the  head.  Impregnation  may  be  effected  without 
lacerating  the  hymen,  which  will  be  found  perfect  at  the  period  of 
labor.  It  usually  yields  to  the  pressure  of  the  head,  but  should  it 
resist  for  too  long  a  time,  a  slight  incision  may  be  made  into  it  by  the 
scalpel,  taking  care  to  prevent  the  laceration  from  extending  into  the 
perineum,  as  the  head  passes  through  the  external  orifice,  by  giving 
careful  support  to  the  perineum. 

4._Where,  from  a  continued  DELAY  OF  THE  CHILD'S  HEAD 

in  the  Pelvic  Cavity,  the  circulation  of  the  parts  becomes  interrupted, 
the  soft  parts  are  apt  to  swell,  thereby  offering  still  greater  opposition 
to  the  advance  of  the  head,  and  which  may  terminate  in  some  structural 
lesion  of  the  parts,  if  prompt -and  energetic  measures  be  not  adopted. 
Dr.  Campbell  observes,  "  Unless  a  practitioner  has  had  the  manage- 
ment of  the  patient  from  the  commencement  of  labor,  he  is  apt  to  view 
this  variety  of  diminished  capacity,  as  arising  from  original  defect  in 
the  development  of  the  bones  themselves." 

TREATMENT. — This  condition  may  be  overcome,  to  a  great 
extent,  by  emollient  vaginal  injections,  or  injections  of  warm  Lard  or 
Oil,  and  if  necessary,  relaxation  may  be  produced  by  the  adminis- 
tration of  Gelsemium  or  Lobelia.  Should  the  pains  be  feeble,  labor 
may  be  facilitated  by  an  injection  into  the  rectum  of  compound 
tincture  of  Lobelia  and  Capsicum,  slightly  diluted  with  water;  or 
Macrotys,  Ergot,  etc.,  may  be  exhibited  according  to  the  directions 


390  KING'S  ECLECTIC  OBSTETRICS. 

heretofore  given,  when  treating  of  inefficient  action  of  the  uterus. 
The  forceps  have  been  advised*,  but  I  should,  in  these  instances,  fear 
some  injury  to  the  parts  from  their  employment.  I  have  frequently 
given  the  Gelsemium  to  cause  relaxation,  and  when  produced,  have 
followed  it  with  Ergot,  with  the  happiest  results,  in  cases  requiring  an 
expeditious  delivery,  where  the  pains  were  feeble,  with  a  degree  of 
rigidity  or  tumefaction  of  the  soft  parts. 

5.— (EDEMA  OF  THE  LABIA  MAJORA,  is  sometimes  so  great 
at  the  time  of  labor,  as  nearly  to  obliterate  the  vaginal  entrance, 
rendering  the  delivery  difficult  and  very  painful ;  and  the  pressure  of 
the  fetal  head  in  its  passage  over  the  tumefied  parts,  may  cause  an 
extensive  rupture,  or  produce  gangrene.  The  same  treatment  may  be 
pursued  as  in  the  preceding  instance,  but,  if  the  tumefaction  be  very 
excessive,  or  the  labor  considerably  advanced,  it  is  recommended  to 
puncture  the  engorged  parts  with  the  lancet,  in  different  places,  the 
number  of  punctures  depending  on  the  extent  and  degree  of  oedema. 
But  it  must  be  remembered  that  the  parts  after  having  been  punctured 
are  liable  to  inflammation  and  sloughing. 


CHAPTER   XXXI. 

ON   DIFFICULT    LABOR,    FROM   TUMORS,    PELVIC   DEFORMITIES,    ETC. 

i 

6. — THE  capacity  of  the  pelvis  is  occasionally  diminished  during 
labor,  by  the  presence  of  Tumors  in  its  Cavity.  These  tumors  may 
vary  in  their  size,  consistency,  and  pathological  characters ; 'they  may- 
be osseous,  fibrous,  adipose,  steatomatous,  sarcomatous  or  scirrhus,  and 
the  difficulty  occasioned  by  them,  will  depend  upon  their  size  and 
degree  of  solidity.  The  history  and  surgical  management  of  these 
tumors,  together  with  other  details,  are  not  within  the  province  of  this 
work,  in  which  I  will  merely  refer  to  the  diagnostic  signs,  and  the 
indications  for  treatment  when  they  interfere  with  the  progress  of  labor. 

A  hard,  bony  tumor  of  extremely  rare  occurrence,  termed  EX- 
OSTOSIS,  has  been  met  with.  It  takes  its  origin  from  some  portion 
of  the  osseous  parietes,  more  commonly  from  the  sacro-iliac  symphy- 
sis,  and  sometimes  from  the  first  bone  of  the  sacrum,  from  the  last 


DIFFICULT    LABOR — FROM   PELVIC   DEFORMITY.  391 

lumbar  vertebra,  from  the  internal  surface  of  one  of  the  ischia,  or 
from  some  portion  of  the  posterior  face  of  the  pubic  bones:  and  may 
be  detected  by  its  hard,  knotty,  and  irregular  feel,  its  insensibility  to 
pressure,  its  immobility,  and  its  projection  into  the  interior  of  the 
vaginal  canal,  but  always  covered  by  the  wall  of  this  canal. 

TREATMENT. — If  the  presence  of  the  exostosis  be  known  at  an 
early  period  of  gestation,  it  would  be  proper,  according  to  circum- 
stances, to  effect  an  abortion,  or  induce  premature  delivery.  At  full 
term,  it  may  be  possible,  that  when  the  tumor  is  very  small,  the  labor 
will  progress  without  assistance,  but  when  it  is  large,  so  as  to  mate- 
rially interfere  with  the  capacity  of  the  pelvic  diameters,  the  case 
assumes  a  more  serious  aspect.  As  we  can  not  remove  this  obstruction 
by  an  operation,  we  must  be  governed  by  the  nature  of  the  case.  If 
there  is  a  probability  that  the  head  may  pass,  it  will  be  prudent  to 
wait  until  symptoms,  demanding  artificial  delivery,  present  themselves, 
when  the  labor  may  be  terminated  by  the  forceps,  or  perhaps  the  per- 
forator. When  the  diminution  of  the  pelvic  cavity,  from  this  cause, 
is  so  great  that  the  fetus  can  not  pass  through  the  vagina,  the  only 
chance  for  the  mother  will  be  in  the  performance  of  the  Cesarean 
section,  or  the  Porro  operation,  a  description  of  which  will  be  found 
in  another  part  of  this  work.  Fortunately,  these  instances  are  rare; 
I  have  never  met  with  one. 

7. — Other  osseous  tumors  may  occasionally  render  a  labor  difficult, 
as  OSTEO-SARCOMA  of  the  pelvis;  this  is  very  difficult  to  distin- 
guish from  exostosis ;  it  presents  greater  inequalities,  has  a  semi- 
cartilaginous  softness,  a  degree  of  depressibility,  and  at  some  parts  of 
its  surface  crepitation  may  be  observed.  From  the  depressibility  of 
this  tumor,  the  pressure  of  the  head  may  flatten  it,  and  effect  a  suffi- 
cient amplification  of  the  parts  to  admit  of  the  passage  of  the  fetus ; 
and  should  the  natural  efforts  fail,  or  symptoms  appear  requiring 
interference,  the  labor  may  be  terminated,  according  to  circumstances, 
as  in  the  preceding  difficulty. 

Sometimes  the  pelvic  cavity  may  be  diminished  by  bony  protuber- 
ances, depending  upon  irregular  consolidation  of  fractures  in  the  part, 
or  perforation  of  a  carious  acetabulum  by  the  head  of  the  femur,  etc. 
In  these  cases,  whatever  may  be  the  situation  of  the  protuberance,  the 
indications  for  treatment  will  be  the  same  as  in  pelvic  deformities. 

8.— ENCYSTED  TUMORS,  may  adhere  to  the  cervix  uteri,  or  to 
the  vaginal  walls ;  they  are  usually  round,  well-defined,  movable, 
elastic,  and  sometimes  fluctuating,  and  require  the  same  treatment  as 


392  KING'S  ECLECTIC  OBSTETRICS. 

heretofore  named  for  other  tumors,  as  do  also  those  of  a  Scirrhwt  or 
Phlegmonous  character,  Polypi,  and  various  Excrescences,  and  Syphilitic 
Vegetations  which  may  be  found  on  the  external  parts  of  the  genera- 
tive organs. 

From  the  great  fatality  which  attends  the  presence  of  pelvic  tumors, 
as  obstacles  to  delivery,  it  must  be  regarded  as  a  fortunate  matter  that 
their  occurrence  is  not  very  frequent.  Perhaps,  less  fatality  would 
attend  these  cases,  when  known  at  an  early  period,  and  both  mother 
and  child  be  saved,  were  the  induction  of  premature  labor  accom- 
plished ;  although,  it  is  by  no  means  improbable,  that  even  at  the 
seventh  month,  instances  may  be  met  with  which  will  offer  an  obstacle 
to  the  operation,  and  with  these,  the  production  of  an  early  abortion 
affords  the  only  chance  of  safety  for  the  mother. 

As  a  general  rule  of  action,  in  all  cases  of  tumors  at  full  term,  the 
first  attempt  of  the  practitioner  should  be  to  push  the  tumor  up  above 
the  superior  strait,  beyond  the  head,  so  as  to  remove  its  interference 
with  the  advance  of  the  latter.  And  the  operator  will  be  more  likely 
to  succeed  by  placing  the  patient  on  her  knees,  with  the  pelvis  eleva- 
ted, and  the  breast  on  the  bed,  in  a  line  with  the  knees ;  this  position 
deprives  the  patient  of  any  tenesmic,  or  bearing-down  power,  beside 
causing  the  uterus  to  gravitate  further  from  the  pelvis,  in  a  direction 
toward  the  epigastrium,  and  thus  affording  greater  space  into  which 
the  tumor  may  be  placed.  The  manipulation  may  be  conducted 
according  to  circumstances,  with  the  hand  in  the  vagina,  or  one  or  two 
fingers  in  the  rectum,  or  both  combined. 

Where  the  tumor  can  not  thus  be  placed  out  of  the  way,  it  is  recom- 
mended to  puncture  it  with  a  trocar,  and  in  case  this  fails,  to  perforate 
the  child's  head,  either  of  which  operations  do  not  always  lessen  the 
danger  to  the  mother.  In  relation  to  puncturing  or  incising  the  pos- 
terior vaginal  wall,  in  these  tumor  cases,  Prof.  Meigs  remarks  in  his 
valuable  work  on  Obstetrics,  "  I  do  not  feel  at  liberty  to  recommend 
such  an  operation  in  this  volume — an  operation  which  could  only  be 
legitimately  performed,  upon  due  and  mature  consideration  with  the 
most  acute  and  able  practitioners  of  the  vicinity.  They  alone  should 
feel  themselves  vested  with  the  authority  to  act  under  such  terrible 
circumstances.  I  merely  remark,  en  passant,  that  an  incision  into  the 
posterior  wall  of  the  vagina,  should  it  even  have  the  good  effect  suffi- 
ciently to  reduce  the  size  of  the  tumor,  fearfully  exposes  the  patient 
to  the  risk  of  vaginal  laceration  from  the  subsequent  distension  by  the 
descending  head,  and  the  escape  of  the  child  into  the  peritoneal  sac. 


DIFFICULT    LABOR — FROM    PELVIC    DEFORMITY.  393 

A  small  aperture  in  the  thin  posterior  paries  of  the  tube,  is  more 
likely  to  yield  and  become  a  frightful  laceration,  than  to  resist  the  dis- 
tending force  of  the  advancing  head."  These  remarks,  from  one  of 
the  most  eminent  accoucheurs  of  America,  are  entitled  to  the  serious 
consideration  of  every  medical  man.  Up  to  this  period,  I  have  met 
with  only  one  instance  of  tumor  offering  an  impediment  to  delivery  ; 
it  was  a  cauliflower  excrescence  of  the  cervix,  in  a  female  with  her 
fifth  child,  and  terminated  fatally. 

DEFORMITIES  OF  THE  PELVIS,  are  another  cause  of  pro- 
tracted and  difficult  labors,  not  unfrequently  rendering  the  descent  of 
the  child  impracticable,  and  are  much  more  common  to  the  women  of 
Europe  than  to  those  of  America.  In  another  part  of  this  work  I 
have  referred  to  the  character  of  these  malformations,  and  the  method 
of  determining  them  ;  it  now  remains  to  speak  of  the  management  of 
labor  when  they  are  present. 

9._The  ABNORMALLY  LARGE  PELVIS,  can  scarcely  be  con- 
sidered a  deformity  ;  but  as  the  head  of  the  child  may  meet  with  but 
little  resistance  in  its  passage  through  the  canals,  the  various  motions 
of  flexion,  rotation,  etc.,  may  not  take  place  at  all,  or  else  be  very 
imperfectly  effected,  and  thus  modify  the  labor.  The  consequences 
which  may  result  in  these  kind  of  labors  from  deficient  resistance, 
have  already  been  named.  Where  the  labor  proceeds  rapidly,  the 
child  may  unexpectedly  be  expelled  and  fall  upon  the  floor,  even 
before  the  practitioner  has  deemed  it  advisable  to  make  the  usual  pre- 
liminary preparations.  In  these  cases,  the  best  method  of  manage- 
ment, when  called  in  time,  is,  to  prevent  the  head  from  being  too 
hastily  expelled,  by  pressure  upon  it  during  a  pain,  giving  firm  sup- 
port to  the  perineum  until  it  is  sufficiently  yielding  to  allow  the  head 
to  pass  without  causing  a  laceration,  and  to  guard  against  hemorrhage 
by  pressure  over  the  uterine  globe.  After  delivery,  the  patient  should 
be  kept  in  the  horizontal  posture,  for  a  longer  time  than  usual. 

10.— The  DWARFISH  PELVIS,  will  offer  an  impediment  to 
labor,  according  to  the  degree  of  contraction  present;  the  labor  may 
be  accomplished  by  the  natural  powers,  but  it  will  be  tedious,  difficult, 
and  attended  with  much  suffering,  and  perhaps,  from  the  long-con- 
tinued compression  of  the  head,  result  in  the  death  of  the  child ;  or, 
it  may  be  impossible  for  the  child  to  be  born  without  assistance.  And, 
indeed,  the  same  observations  will  apply  to  the  Unequally  Contracted 
Pelvis,  and  the  Obliquely  Distorted  Pelvis. 


394  KING'S  ECLECTIC  OBSTETRICS. 

The  character  of  the  labor,  in  these  instances,  will  depend  entirely 
upon  the  amount  of  deformity  which  may  be  arranged  as  follows: 
1st.  Where  the  diminution  of  the  pelvic  diameters  is  not  so  great  but 
that  the  child  may  be  born,  after  a  long  time,  by  the  natural  powers, 
aided,  in  most  cases,  by  the  forceps,  for  the  application  of  which  there 
will  be  found  sufficient  space.  2d.  Where  the  diminution  of  the 
pelvic  diameters  renders  it  impossible  for  the  head  to  advance,  and  the 
forceps  can  not  be  applied  for  want  of  space,  and,  consequently,  the 
only  resource  is  the  perforator.  3d.  Where  the  pelvic  canal  is  so 
reduced  in  size,  that  even  a  mutilated  child  could  not  be  extracted. 

The  difficulty  of  the  labor  will  not  depend  so  much  upon  the  positive 
size  of  the  pelvic  diameters  themselves,  as  upon  their  adaptation, 
relatively,  to  the  diameters  of  the  fetal  head;  for,  though  the  pelvis 
may  be  considerably  contracted,  yet,  if  the  child's  head  be  smafl,  the 
labor  may  progress  with  comparatively  little  difficulty.  A  pelvis, 
whose  small  diameter  is  less  than  three  inches,  may  generally  be  con- 
sidered as  one  through  which  a  living  child  can  not  pass ;  on  this 
point,  however,  it  may  be  proper  to  state,  that  accoucheurs  vary  in 
their  estimate,  some  placing  the  limit  at  two  inches,  some  at  two  and 
a  half,  and  others  at  three,  and  even  three  and  a  quarter  inches.  In 
instances  where  the  small  diameter  is  less  than  three,  but  exceeds  two 
inches,  the  labor  will  belong  to  the  second  arrangement  or  class, 
as  given  above;  in  such  cases  the  forceps  could  not  be  employed 
advantageously,  or  if  an  attempt  were  made  to  use  them,  it  would, 
undoubtedly  prove  useless,  and  perhaps  injurious — the  perforator  and 
crochet  would  be  demanded  here.  Authors  likewise  vary  in  the  limit 
of  measurement  in  these  labors  requiring  the  mutilating  instruments, 
some  placing  \t  at  one  and  a  half  inches,  and  others  at  one  and  three 
quarters,  and  two  inches.  When  the  small  diameter  is  below  two 
inches,  the  labor  belongs  to  the  third  arrangement,  and  will,  very 
probably,  require  the  Cesarean  operation  before  the  child  can  be 
removed. 

When  there  is  a  deformity  of  the  pelvis,  we  are  informed  by  Dr. 
Rigby,  that  the  uterine  contractions  are  frequently  irregular  during 
the  first  stage,  of  labor,  exerting  but  little  influence  in  dilating  the  <>s 
uteri ;  the  head  remains  high  up,  does  not  descend  against  the  os  uteri, 
and  shows  no  disposition  to  enter  the  pelvic  cavity — beinir  pushed 
forward  by  the  promontory  of  the  sacrum,  it  rests  upon  the  pubic 
.syinphysis,  pressing  forcibly  ag-.iinst  it.  The  mode  of  determining 
deformity  a:  the  superior  strait,  has  been  already  explained  in  another 
part  of  the  work.  When  the  deformity  is  in  the  cavity  or  at  the  in- 


DIFFICULT    LABOR — FROM    PELVIC    DEFORMITY.  395 

ferior  strait,  it  is  detected  with  much  less  difficulty,  as  the  parts  are 
more  readily  reached ;  we  will  discover  that  the  head  makes  no  advance- 
ment during  a  pain,  and  if  the  finger  be  passed  around  during  the 
absence  of  pain,  the  head  will  be  found  larger  than  the  canal  through 
which  it  has  to  pass.  When  the  labor  is  allowed  to  proceed  without 
interference  in  these  extremely  deformed  pelves,  various  symptoms 
may  present,  which  are  generally  met  with  during  the  second  stage, 
as:  inefficient  contractions,  exhaustion,  and  febrile  symptoms,  inflam- 
mation and  sloughing  of  the  soft  parts,  the  result  of  long  and  forcible 
pressure  of  the  head,  and  which  may  occur  at  either  of  the  straits,  or 
in  the  cavity,  and  may,  likewise,  penetrate  into  the  bladder,  or  rectum; 
rupture  of  the  uterus  not  unfrequently  occurs  in  these  cases.  The  child 
may  have  one  or  more  bones  of  the  cranium  fractured,  or  the  pressure 
may  cause  inflammation  or  sloughing  of  the  scalp,  or  its  death  may  be 
occasioned  by  strong  and  continued  compression  of  the  head. 

TREATMENT.— This  will  depend  much  upon  the  class  to  which 
the  deformity  belongs;  no  positive  or  fixed  rule  can  be  laid  down;  if 
it  be  of  the  first  class,  a  fair  trial  should  be  given  to  the  natural  powers, 
and  if  they  be  found  insufficient  to  effect  the  child's  expulsion,  or  if 
symptoms  of  exhaustion  appear,  assistance  should  be  given  with  the 
forceps,  provided  there  be  space  enough  for  their  application.  If  the 
case  belongs  to  the  second  or  third  class,  I  deem  it  advisable  to  operate 
at  as  early  a  period  as  possible,  before  the  system  of  the  patient  has 
become  exhausted  from  the  long-continued  exertion  and  sufferings  of 
the  labor,  thereby  materially  increasing  the  chances  of  a  favorable 
result.  In  instances  wrhere  the  perforator  is  indicated,  the  child  is 
generally  dead  from  the  pressure,  before  the  symptoms  have  arrived  at 
a  point  demanding  the  operation.  In  alt  cases  where  deformity  of  the 
pelvis  is  suspected  during  labor,  the  practitioner  should  at  once  pro- 
ceed by  a  careful  examination  to  determine  the  character  and  location 
of  the  distortion,  and  the  method  of  .management  should  be  decided 
upon  only  after  a  consultation  with  experienced  accoucheurs. 

The  following  extract  from  Dr.  R.  Lee's  Lectures  on  Midwifery, 
relative  to  the  treatment  of  pelvic  deformities,  will,  no  doubt,  prove 
acceptable  to  the  reader ;  he  observes  :  "  In  cases  of  slighter  distor- 
tion of  the  pelvic,  it  is  impossible  to  predict  at  the  commencement 
of  labor  whether  the  head  will  pass  or  not,  and  while  it  continues  to 
advance  and  no  unfavorable  symptoms  are  present,  you  ought  not  to 
interfere — wait  patiently  and  see  what  nature  can  do.  If  the  head 
descends  so  low  into  the  cavity  of  the  pelvis  that  an  ear  can  be  felt, 


396  KING'S  ECLECTIC  OBSTETRICS. 

and  the  os  uteri  is  fully  dilated,  and  there- is  room  to  pass  up  the  blades 
of  the  forceps  without  the  employment  of  much  force,  it  is  always 
proper,  when  delivery  becomes  necessary,  to  attempt  to  extract  the 
head  with  the  forceps.  It  is  necessary,  however,  to  remember  that 
sloughing  is  apt  to  follow  the  use  of  the  forceps  where  the  soft  parts  have 
been  long  pressed  upon  by  the  head,  and  that  perforation  of  the  head 
is  a  much  safer  operation  for  the  mother,  when  the  distortion  is  con- 
siderable. 

"The  employment  of  the  long  forceps,  in  cases  of  distorted  pelvis, 
has  been  recommended  by  Baudelocque,  Boivin,  La  Chapelle,  Capuroi>, 
Maygrier,  Velpeau,  and  Flammant,  whose  works  contain  ample  in- 
structions for  its  use,  before  the  head  of  the  child  has  entered  the  brim 
of  the  pelvis;  and  the  la"st  of  these  writers  has  expressed  his  belief  that 
the  instrument  is  more  frequently  required  while  the  head  of  the  child 
remains  above  the  superior  aperture  of  the  pelvis,  than  after  it  has 
descended  into  the  cavity. 

"In  thi«  country  there  are  no  practitioners  of  judgment  and  ex- 
perience, who  have  frequent  resource  to  the  forceps,  or  who  employ  it 
before  the  orifice  of  the  uterus  is  fully  dilated,  and  the  head  of  the 
child  has  descended  so  low  into  the  pelvis  that  an  ear  can  be  felt,  and 
the  relative  position  of  the  head  to  the  pelvis  accurately  ascertained. 
The  instrument  is  very  seldom  used  in  England  where  the  pelvis  i.s 
much  distorted,  or  where  the  soft  parts  are  in  a  rigid  and  swollen  state ; 
but  it  is  had  resource  to,  where  delivery  becomes  necessary  in  conse- 
quence of  exhaustion,  hemorrhage,  convulsions,  and  other  accidents 
which  endanger  the  life  of  the  mother.  It  is  used  solely  with  the 
view  of  supplying  that  power  which  the  uterus  does  not  possess." 

Again,  "  Where  there  exists  a  great  degree  of  distortion  of  the  brim 
of  the  pelvis,  you  may  be  unable  to  determine,  positively,  the  distance 
between  the  base  of  the  sacrum  and  symphysis  pubis;  and  it  is  not 
necessary,  for  practical  purposes,  to  do  so  with  mathematical  accuracy  ; 
but  when  it  is  under  two  inches  and  a  half,  you  will  readily  discover, 
if  you  have  had  considerable  experience,  on  making  the  ordinary 
examination,  from  the  unusual  manner  in  which  the  sacrum  projects, 
that  it  is  impossible  for  a  child  at  the  full  period  to  pass  through  it. 
If  labor  has  commenced  at  the  full  period  of  pregnancy,  and  you 
discover,  before  it  has  continued  many  hours,  that  the  pelvis  is  greatly 
distorted,  and  that  the  child  can  not  possibly  pass  alive,  no  advantage 
can  result  from  allowing  the  labor  to  endure  till  the  patient  is  ex- 
hausted, and  you  are  satisfied  that  the  difficulty  can  not  be  overcome 


DIFFICULT    LABOR FROM    PELVIC    DEFORMITY.  397 

by  the  powers  of  the  constitution.  In  such  a  case  delay  is  dangerous, 
and  there  is  nothing  which  can  save  the  woman's  life  but  opening  the 
child's  head  with  the  perforator,  and  extracting  it  with  the  crochet. 
But  this  should  never  be  had  recourse  to  without  a  regular  consulta- 
tion of  experienced  practitioners,  and  before  it  has  been  placed  beyond 
all  doubt,  by  the  most  candid  investigation,  that  the  delivery  can  be 
accomplished  in  no  other  manner,  so  as  to  preserve  the  mother's  life. 
"  In  the  greater  number  of  cases  of  difficult  labor  from  a  high 
degree  of  distortion  of  the  pelvis,  which  have  come  under  my  observa- 
tion, where  it  has  been  the  first  child,  the  process  has  been  allowed  to 
go  on  till  the  efforts  of  the  patient  had  been  nearly  discontinued,  or 
had  ceased  entirely,  and  the  favorable  period  for  operating  was  lost. 
In  some  cases,  even  when  the  duration  of  the  labor,  and  the  local  and 
constitutional  symptoms,  have  made  it  manifest  that  such  interference 
was  justifiable  and  necessary,  I  have  unfortunately  delayed  too  long  to 
deliver,  in  consequence  of  employing  the  stethoscope,  and  ascertaining 
that  the  child  was  alive.  In  cases  of  extreme  distortion  of  the  brim 
of  the  pelvis  the  proper  practice  is,  to  perforate  the  head  as  soon  as 
the  os  uteri  is  sufficiently  dilated  to  admit  of  the  operation  being  done 
with  safety,  and  afterward  leaving  the  patient  in  labor  till  the  head 
has  partially  entered  the  brim,  and  the  os  uteri  is  considerably  dilated. 
There  can  be  no  doubt  that,  in  some  cases,  it  is  right  to  interfere 
before  we  certainly  know  that  the  child  has  been  destroyed  by  the 
pressure;  but  we  have  nothing  here  to  do  with  the  question  respecting 
the  life  or  death  of  the  child ;  our  conduct  will  be  biased  if  we  en- 
deavor to  solve  this  question.  We  have  only  to  determine  positively, 
that  delivery  is  absolutely  necessary  to  save  the  mother's  life,  and  that 
it  is  impossible  for  the  head  of  the  child  to  pass,  till  its  volume  is 
reduced.  Pare*,  Guillemeau,  Mauriceau,  Portal,  Puzos,  Levret,  Smellie, 
and  all  the  best  accoucheurs  who  have  since  appeared  in  Britain,  have 
performed  the  operation  of  craniotomy  in  many  cases  of  distortion 
from  rickets  and  malacosteon,  without  reference  to  the  condition  of 
the  fetus.  (  True  religion  and  the  common  sense  of  mankind,'  observes 
Dr.  Denham,  '  appear  to  have  nothing  contradictory.  The  doctrine 
they  teach,  of  its  being  our  duty  to  do  all  the  good  in  our  power,  and 
to  avoid  the  mischief  we  can,  is  applicable  to  the  exigencies  of  every 
state,  and  we  may  be  easily  reconciled  to  it  on  the  present  occasion. 
In, some  cases  of  difficult  parturition,  it  is  not  possible  that  the  lives, 
both  of  the  mother  and  child,  should  be  preserved.  Of  the  life  or 
death  of  the  mother,  we  can,  under  all  circumstances,  be  assured:  of 


398  KING'S  ECLECTIC  OBSTETRICS. 

the  life  or  death  of  the  child,  there  is  often  reason  to  doubt,  when  we 
are  called  upon  to  decide  and  to  act.  The  destruction  of  the  mother 
would  not,  in  the  generality  of  cases  which  may  bring  the  operation 
of  which  we  are  speaking  under  contemplation,  contribute  to  the 
preservation  of  the  child ;  but  the  treatment  of  the  child  as  if  it  were 
already  dead,  with  as  much  certainty  of  success  as  is  found  in  other 
operations,  secures  the  life  of  the  parent.  It  then  becomes  our  duty, 
and  is  agreeable  to  our  reason,  to  pursue  that  conduct  which  will  give 
us  the  most  probable  chance  of  doing  good  ;  that  is,  of  saving  one  life, 
when  two  lives  can  not  possibly  be  preserved.' 

"  'The  only  means  of  effecting  delivery/  observes  Dr.  Collins, 
'where  the  disproportion  between  the  head  of  the  child  and  the  pelvis 
is  so  great  as  to  prevent  us  reaching  the  ear  with  the  finger,  is  by 
reducing  the  size  of  the  head  and  using  the  crochet.  This  is,  how- 
ever, an  operation  that  no  inducement  should  tempt  any  individual  to 
perform,  except  the  imperative  duty  of  saving  the  life  of  the  mother 
when  placed  in  imminent  danger.  I  have  no  difficulty  in  stating,  that 
after  the  most  anxious  and  minute  attention  to  this  point,  that  where 
the  patient  has  been  properly  treated  from  the  commencement  of  her 
labor;  where  strict  attention  has  been  paid  to  keep  her  cool,  her  mind 
«asy;  where  stimulants  of  all  kinds  have  been  prohibited,  and  the 
necessary  attention  paid  to  the  state  of  the  bowels  and  bladder ;  that, 
under  such  management,  the  death  of  the  child  takes  place  in  labori- 
ous and  difficult  labor  before  the  symptoms  b«come  so  alarming  as  to 
cause  any  experienced  physician  to  lessen  the  head.  This  is  a  fact 
which  I  have  ascertained  beyond  all  doubt  by  the  stethoscope,  the  use 
of  which  has  exhibited  to  me  the  great  errors  I  committed  before  I 
was  acquainted  with  its  application  to  midwifery,  viz :  in  delaying  the 
delivery,  often,  I  have  no  doubt,  so  as  to  render  the  result  precarious 
in  the  extreme,  and  in  some  cases  even  fatal.' 

"  The  operation  of  craniotomy  is  now  performed  by  all  British 
practitioners  of  reputation,  whether  the  child  be  alive  or  dead,  if  the 
condition  of  the  mother  is  such  as  to  render  delivery  absolutely  neces- 
sary, and  the  head  of  the  child  is  beyond  the  reach  of  the  forceps,  or 
where,  from  distortion  of  the  pelvis,  or  rigidity  of  the  os  uteri  and 
vagina,  it  can  not  be  extracted  if  its  volume  is  not  reduced.  This 
operation  is  performed  from  a  conscientious  belief  and  deep  conviction 
that  if  neglected  to  be  done  at  a  sufficiently  early  period,  the  mother's 
life  will  be  sacrificed,  and  the  life  of  the  mother  is  considered  to  be 
much  more  important  than  that  of  the  child.  Some  continental  writers 


DIFFICULT    LABOR  -  FROM    FELVIC    DEFORMITY.  399 

affirm,  but  I  believe  unjustly,  that  in  England  we  have  frequently 
recourse  to  craniotomy  without  due  consideration,  and  without  proper 
regard  to  the  life  of  the  child;  and,  whatever  the  state  of  the  parent 
may  be,  they  refuse  to  open  the  head  till  they  can  obtain  certain  evi- 
dence, which,  in  some  cases,  it  is  impossible  to  obtain,  that  it  is  dead. 
'  Xothing  could  excuse  the  conduct  of  the  practitioner/  says  Baude- 
locque,  '  who  would  perforate  the  head  of  a  child  without  previously 
knowing  with  certainty  that  it  was  not  alive,  a  circumstance  which 
can  only  authorize  us  to  employ  the  perforator  and  crotchet.'  By  fol- 
lowing this  erroneous  principle,  the  lives  of  both  mother  and  child 
would,  I  believe,  in  the  majority  of  cases,  be  sacrificed." 

As  will  be  noted,  since  reading  the  preceding  pages,  craniotomy,  or 
the  perforation  of  the  skull  and  evacuation  of  the  brain  contents,  is 
the  operation  commonly  resorted  to,  to  overcome  the  disproportion 
existing  between  the  child's  head  and  the  parturient  canal.  Mechan- 
ical obstacles  to  natural  delivery  are  more  frequent  than  one  would  at 
first  suspect;  statistics  indicate  that  fully  seven  thousand  children  an- 
nually, suffer  embriotomy  in  the  United  States  alone. 

This  subject  is  at  present,  owing  to  the  terrible  mortality  reported, 
receiving  the  attention  of  the  foremost  obstetricians;  whether  crani- 
otomy is  ever  justifiable  if  the  child  is  alive  is  doubted;  as  to  whether 
some  protection  should  not  be  offered  in  the  interest  of  the  child,  etc. 

The  saving  of  the  mother's  life  should,  under  all  circumstances,  be 
the  first  consideration,  and  to  that  end  every  effort  should  be  directed. 
But  in  guarding  her  interests,  is  there  not  often  reckless  sacrifice  of 
the  child's  life  ?  Should  there  not  be  an  awakening  to  a  keener  sense 
of  responsibility  in  such  cases  ?  In  addition  to  premature  labor,  which 
I  believe,  as  a  rule,  should  be  induced,  when  the  diagnosis  can  be  made 
at  the  proper  time,  there  is  but  one  other  alternative  suggested  as  a 
substitute  to  craniotomy,  in  cases  where  the  diameters  of  the  parturient 
outlet  fall  so  far  below  normal  as  to  render  both  natural  and  instru- 
mental delivery  impossible,  and  that  is  abdominal  section.  Abdom- 
inal section  includes  both  the  Cesarean  and  Porro's  operations,  which 
will  be  clearly  defined  in  a  subsequent  chapter.  In  view  of  the  ad- 
vancement made  in  abdominal  surgery,  during  the  past  few  years, 
statistics  clearly  indicate  a  marked  falling  off  in  the  death  rate,  and 
one  of  the  operations  looking  to  the  saving  of  the  child  does  not  ma- 
terially increase  the  maternal  mortality.  In  view  of  this  fact,  crani- 
otomy, it  seems,  should  not  be  executed  until  the  circumstances  of  each 
individual  case  are  carefully  considered,  and  the  concurrence  and 


400  KING'S  ECLECTIC  OBSTETRICS. 

endorsement    of  eminent    consultation    is    obtained.     The    reader   is 
referred  to  the  chapter  on  Abdominal  Section  for  further  details. 

The  operation  of  turning  has  been  recommended,  in  cases  of  pelvic 
deformity,  by  some  authors.  The  advantages  of  this  method,  revived 
by  the  late  Dr.  Simpson,  of  Edinburgh,  Scotland,  are,  in  the  first 
place,  that  it  can  be  performed  at  an  early  period  of  the  labor,  in 
which  respect  it  has  greatly  the  advantage  over  craniotomy,  which 
must  be  performed  at  a  later  period,  and  after  the  woman  has  become 
more  or  less  exhausted  by  her  long  continued  sufferings,  at  the  same 
time  that  she  escapes  the  risk  of  injuries  to  the  vagina  and  soft  parts 
by  instruments.  It  also  affords  a  greater  chance  for  the  safety  of  the 
fetus.  The  idea  upon  which  this  operation  is  based  is,  that  the 
bimastoid  diameter  of  the  fetal'  head  being  from  half  an  inch  to  three 
quarters  of  an  inch  smaller  than  the  biparietal,  the  head,  thus  turned, 
is  somewhat  wedge-shaped,  the  small  part  being  at  its  base,  the  broad 
part  at  the  vertex.  By  delivering  the  fetus  in  the  manner  named,  the 
small  part  of  this  wedge  is  first  brought  down,  and  the  broad  part- 
especially  as  it  is  kno\vn  that  the  biparietal  diameter  may  be  com- 
pressed to  a  considerable  extent — may,  very  probably,  likewise  be 
drawn  through  the  contracted  parts.  That  there  are  instances  in 
which  this  operation  has  proved  successful,  can  not  be  doubted,  if  the 
statements  published  in  our  medical  journals  from  many  accoucheurs 
are  to  be  believed.  It  appears  to  have  been  more  successful  in  the 
dwarfish  and  the  obliquely  distorted  pelvis,  and  when  the  antero- 
posterior  diameter  of  the  superior  strait  is  not  less  than  two  and  a 
half  inches;  notwithstanding,  I  consider  the  operation  a  very  haz- 
ardous one,  which  should  never  be  undertaken  without  due  consid- 
eration and  careful  examination;  for  if  it  fails,  the  perils  of  the 
woman  are  increased.  It  must  be  recollected  that — and  especially  in 
cases  of  pelvic  deformity — it  is  not  always  possible  to  tell  how  the 
diameters  of  the  head  may  compare  with  those  of  the  pelvis;  and,  in 
turning,  the  head  may  be  so  placed  as  not  only  to  expose  the  female 
to  the  pains  and  difficulties  incident  to  the  operation,  but  to  the 
subsequent  difficulties  attending  the  employment  of  the  forceps, 
or  perhaps  the  perforator,  one  of  which  will  most  certainly  be  required 
in  case  of  turning  from  error  of  diagnosis;  beside  affording  not  the 
least  chance  for  the  safety  of  the  child. 

After  the  delivery,  every  means  should  be  employed  to  guard 
against  sloughing;  warm  water  should  be  injected  into  the  vagina  two 
or  three  times  a  day ;  or  we  may  administer  internally  Hamamelis  or 
Collinsonia.  Febrile  or  inflammatory  symptoms  may  be  combated 


DIFFICULT    LABOR FUOM    PELVIC    DEFORMITY.  401 

with  the  Sp.  Tr.  of  Aconite,  Veratrum,  Gelsemium,  Macrotys,  etc. 
Water,  as  hot  as  can  be  endured,  in  which  a  small  amount  of  Borax 
or  Chlorate  of  Potash  has  been  dissolved,  used  as  an  injection,  will 
often  prove  advantageous  in  connection  with  the  internal  agents;  and, 
to  relieve  excessive  weakness  or  prostration,  it  may  become  necessary 
in  some  cases  to  use  stimulants,  either  Wines  or  diluted  Brandy,  until 
the  patient  reacts.  Uterine  tonics,  as  Macrotys,  Pulsatilla,  Phyto- 
lacca,  or  Nux  Vomica,  may  be  indicated ;  and  later,  the  bitter  or 
chalybeate  tonics  called  for. 

In  all  instances  where  a  deformity  of  the  pelvis  is  known  to  exist, 
and  especially  when  from  careful  measurement,  or  the  results  of  a 
previous  labor,  it  is  ascertained  that  a  living  child  can  not  be  born  at 
full  term,  the  induction  of  premature  labor  should  be  unhesitatingly 
performed;  likewise,  in  cases  where  the  life  of  the  mother  would  be 
endangered  from  the  difficulty  or  impossibility  of  delivery  at  this 
period.  And  in  those  cases  where,  at  the  seventh  month,  premature 
labor  would  be  hazardous  to  the  mother,  on  account  of  excessive 
diminution  of  the  pelvic  diameters,  or  distortions,  I  should  not  hesitate 
a  mome'nt  in  adopting  measures  to  produce  abortion. 

The  rule  generally  adopted  in  pelvic  deformities  is,  that  when  the 
antero-posterior  diameter  of  the  superior  strait  measures  from 

3^  to  4  inches,  the  forceps  may  answer ; 

2ij  to  3^     "       turning  may  answer  ; 

If  to  2^r     "       craniotomy  required  ; 

Less  than  1%  inches,  Cesarian  section  required. 

If  the  existence  of  the  deformity  be  known  in  time,  the  safety  of 
the  mother,  and  probably  that  of  the  child,  may  be  secured  in  the^rsZ 
two  instances,  by  the  induction  of  premature  delivery  at  the  seventh 
month ;  in  the  third  instance,  turning  may  prove,  successful  at  the 
seventh  month ;  in  the  fourth  instance,  the  production  of  abortion  at 
an  early  period  is  a  justifiable  procedure. 

11. — Occasionally  the  CONDITION  OF  THE  COCCYX  may  be  such  as  to 
render  labor  difficult,  as  from  anchylosis  at  the  sacro-coccygeal  articu- 
lation, from  malposition  due  to  previous  fracture,  from  scrofulous 
disease,  etc.  It  is  only,  however,  when  the  coccyx,  having  become 
fixed,  diminishes  the  diameter  of  the  inferior  strait,  that  it  materially 
interferes  with  labor.  An  examination  will  reveal  whether  it  be  im- 
movable or  anchylosed,  and  the  degree  to  which  it  interferes  with  the 

diameter  of  the  strait,  from  a  curvature  slightly   varying  from    the 
26 


402  KINO'S    ECLECTIC    OBSTETRICS. 

normal  to  one  at  a  right  angle  with  the  apex  of  the  sacrum.  These 
abnormities  of  the  coccyx  are,  fortunately,  extremely  rare  causes  of 
difficult  labor.  The  treatment  consists  according  to  circumstances,  in 
inducing  premature  delivery,  use  of  forceps  or  perforator,  or,  breaking 
down  the  anchylosis,  and  which  will  be  found  an  exceedingly  difficult 
and  painful  operation,  when  undertaken  during  the  progress  of  labor. 

12.— Labor  may  be  rendered  difficult  by  VAGINAL  VESICO- 
CELE,  or  VAGINAL  CYSTOCELE,  in  which  the  urinary  bladder 
falls  from  its  proper  position  in  front  of  the  uterus,  and  descends 
below  the  fetal  head,  overlapping  the  pelvic  brim.  The  head,  in  its 
descent,  pushes  the  fundus  of  the  bladder  before  it  into  the  excavation, 
forming  a  tumor  of  greater  or  less  size  at  the  anterior-superior  part 
of  the  vagina,  and  which,  if  not  timely  relieved,  may  terminate  very 
seriously.  Sometimes  the  depressed  bladder  has  been  found  directed 
to  one  side  of  the  pelvis.  The  patient  experiences  a  sensation  of 
weight  or  fullness  in  the  pelvis,  a  dragging  sensation  about  the 
umbilicus,  .with  a  constant,  but  ineffectual  desire  to  urinate;  though,  a 
small  quantity  of  urine  may  pass  during  each  uterine  contraction.  On 
an  examination  per  vaginam,  the  finger  detects  a  more  or  less  oval 
tumor,  usually  in  front  of  the  pelvis,  which  is  smooth,  soft,  and 
fluctuating  during  the  intervals  between  the  pains,  but  hard  and  tense 
while  they  are  on,  and  painful  on  being  steadily  pressed.  The  head 
of  the  child  is  only  partially  covered  by  it,  and  may  be  felt  by  passing 
the  finger  above  and  behind  it;  but  any  attempt  to  slip  the  finger 
between  the  tumor  and  the  symphysis  pubis,  will  prove  unsuccessful. 
Some  care  will  be  required  lest  it  be  mistaken  for  the  -bag  of  waters, 
or  a  hydrocephalic  head,  and  improperly  punctured. 

TREATMENT.— This  difficulty,  whenever  met  with,  must  be 
promptly  remedied.  A  male  elastic  catheter  should  be  introduced 
into  the  bladder,  having  its  point  directed  backward  and  downward, 
and  to  facilitate  its  introduction,  the  head  may  be  slightly  elevated 
with  one  or  two  fingers;  the  whole  operation  must  be  done  during  the 
absence  of  a  contraction,  and  it  may  be  effected  more  readily  by 
entering  the  point  of  the  catheter,  with  the  hand  below  the  vagina, 
and  as  it  passes  on  toward  the  bladder,  gradually  raising  the  hand. 
After  the  urine  has  been  withdrawn,  the  bladder  must  be  pushed 
upward,  by  one  or  two  fingers,  above  the  top  of  the  pubes,  and  held 
there  till  a  pain  thrusts  the  presenting  part  of  the  child  below  it. 
Should  it  be  impossible  to  introduce  the  catheter,  attempts  must  be 


•  DIFFICULT    LABOR — FROM    PELVIC    DEFORMITY.  403 

made,  during  the  intervals,  to  press  up  the  head,  and  at  the  same 
time  also  press  up  the  tumor,  when,  frequently,  the  urine  will  be 
discharged  without  the  aid  of  a  catheter.  If.  these  attempts  fail,  and 
the  progress  of  the  labor  is  checked  by  the  tumor,  or  a  rupture  of  the 
bladder  is  feared,  from  its  overdistension  and  from  the  pressure,  the 
only  resource  is  to  puncture  the  presenting  inferior  surface  of  the 
bladder  with  a  very  fine  trocar,  having  a  consultation  previously,  if 
possible,  with  some  skillful  physician.  In  these  cases,  the  patient 
should  be  carefully  watched  after  delivery,  evacuating  the  bladder  at 
once,  and  not  allowing  it,  for  some  days,  to  become  distended,  to  any 
extent,  with  urine. 

As  these  instances  are  more  apt  to  occur  in  the  first  stage  of  labor, 
and  when  the  bladder  is  more  or  less  filled  with  urine,  the  necessity 
for  keeping  the  bladder  evacuated  at  such  a  time,  will  be  readily  seen. 
It  may  be  proper  to  observe  here,  that  no  tumor  in  the  pelvis, 
especially  those  presenting  fluctuation,  should  ever  be  punctured, 
without  having  first  employed  the  catheter,  to  ascertain  that  it  is  not 
vesical. 

13._Very    rarely,    a   CALCULUS    IN    THE   BLADDER   may 

prove  an  obstacle  to  the  labor,  by  projecting  backward,  and  then 
pressed  downward  by  the  head,  thus  seriously  bruising  the  bladder. 
It  is  not  always  easy  to  diagnosticate  this  difficulty ;  it  will  present  as 
a  hard  tumor  of  greater  or  lesser  size,  circumscribed,  painful  on 
pressure,  whether  of  the  finger  or  child's  head; and  the  diagnosis  may 
be  still  further  verified  by  the  introduction  of  a  sound  or  catheter  into 
the  bladder.  Relief  may  be  attempted,  if  the  head  has  not  descended 
too  far,  by  pushing  it  up  above  the  strait,  and  then  pressing  the 
calculus  upward  and  anteriorly.  If,  from  any  cause,  this  can  not  be 
effected,  vaginal  lithotomy,  with  the  consent  of  counsel,  is  advised,  or, 
perhaps,  craniotomy  may  be  preferred. 

14.— COLLECTION  OF  FAECES  IN  THE  RECTUM,  may  inter- 
pose as  an  obstacle  to  the  passage  of  the  head.  These  form  a  rather 
hard,  irregular,  inelastic  tumor,  which  will  be  felt  in  the  situation  of 
the  rectum,  and  which  when  pressed  upon,  downward,  will  slowly 
yield  and  cause  the  escape  of  feces.  An  examination  per  anum  will 
at  once  detect  the  hardened  scybalse.  This  condition  seldom  happens 
except  among  careless  and  inattentive  females,  and  a  proper  attention 
to  the  condition  of  the  bowels  at  the  early  stage  of  labor,  by  the  prac- 
titioner, will  prevent  its  occurrence. 


404  KING'S    ECLECTIC    OBSTETRICS. 

TREATMENT.— The  feces  should  be  removed  by  injections  of 
warm  water;  or,  should  they  be  so  hard  and  compact  as  to  resist  tins- 
method,  it  will  then  become  necessary  to  remove  as  much  as  possible, 
by  a  scoop,  spatula,  or  the  handle  of  a  spoon,  after  which  administer 
an  injection  of  warm  water. 

15. — A  portion  of  intestine  may  become  engaged  in  the  cul  tie  sac 
between  the  rectum  and  the  posterior  wall  of  the  vagina,  and  form  a 
tumor  of  variable  size.  This  VAGINAL  HERNIA,  especially  when 
it  contains  fecal  matter,  opposes  the  descent  of  the  head,  and,  from  the 
pressure  of  the  head  upon  it,  may  terminate  in  serious  inflammation, 
and  even  gangrene. 

TREATMENT. — The  hernia  must  be  reduced  as  promptly  as  pos- 
sible; the  woman  must  be  placed  on  her  knees  and  elbows,  with  the 
hips  elevated,  and  the  intestine  returned  by  pressure  with  two  or  three 
fingers.  In  some  cases  it  may  be  necessary  to  relax  the  system  by 
means  of  Gelsemium  or  Chloroform,  when  the  patient  will  lie  upon 
her  back,  with  the  thighs  flexed  upon  the  abdomen,  and  supported 
there  by  assistants,  while  the  reduction  is  attempted.  If  the  reduc- 
tion can  not  be  accomplished,  the  labor  may  readily  be  terminated  by 
the  forceps  if  required. 

The  principal  abnormal  conditions  of  neighboring  parts  that  may 
interfere  with  th«  normal  progress  of  labor  are : 

1.— RELAXATION  OF  ABDOMINAL  MUSCLES,  or  DIMIN- 
ISHED POWER  OF  ACTION,  and  which  may  be  due  to  some 
existing  disease -interfering  with  -the  voluntary  and  reflex  action  of  the 
associated  muscles  concerned  in  labor  (respiratory  and  abdominal),  as, 
diseases  of  the  lungs,  of  the  heart,  of  the  abdomen  (especially  ascites), 
paraplegia,  etc.;  or,  which  may  be  the  consequence  of  long-continued 
pain,  or  exhaustion,  or  the  persistent  and  improper  use  of  abdominal 
bandages  or  corsets.  It  is  impossible  to  lay  down  any  specific  rules 
for  treatment  in  these  cases,  as  each  one  must  be  managed  according 
to  its  character  and  indications;  the  great  object  during  parturition  is 
not  to  remove  these  causes,  but  to  overcome  their  immediate  influence 
at  this  time  by  the  use  of  measures  to  expedite  delivery.  In  some 
cases,  a  tight  bandage  around  the  abdomen,  with  compress  beneath 
pressing  upon  the  uterine  fundus,  and  changed  and  retightened  from 
time  to  time,  as  may  be  required  from  the  advance  of  the  labor,  will 
be  found  to  answer ;  Strychnia  is  frequently  highly  efficacious  in  some 
other  cases;  Crede's  method,  heretofore  referred  to  may  prove  useful 


DIFFICULT    LABOR FROM    PELVIC    DEFORMITY.  405 

in  a  third  class  of  cases;  Sulphate  of  Quinia,  or  electricity,  with  a 
fourth;  in  others  again,  the  forceps  may  be  required,  or  the  perforator. 
If  the  accoucheur  is  attending  a  patient  during  gestation,  who  is 
laboring  under  serious  disease  of  the  respiratory,  circulatory,  digestive, 
or  other  organs,  that  may  affect  her  seriously  or  dangerously  at  the 
period  of  parturition,  it  may  become  his  duty  to  induce  premature 
delivery. 

2. — The  ovary  is  liable  to  several  diseases,  which  augment  its  volume 
to  an  enormous  extent.  Among  these,  dropsy  and  scirrhus  are  the 
most  common;  and  if,  at  the  time  of  parturition,  an  OVARIAN 
TUMOR  is  present,  it  may  become  a  cause  of  difficult  labor  by 
impeding  the  birth  of  the  child.  Generally,  as  the  ovary  enlarges, 
it  gradually  rises  from  the  pelvic  into  the  abdominal  cavity,  where 
from  its  bulk,  it  may  interfere  with  the  development  of  the  uterus  and 
occasion  a  premature  labor;  or  else,  by  pressing  this  organ  to  the  side 
opposite,  it  may  give  rise  to  a  difficult  labor,  by  producing  a  uterine 
obliquity.  Or  it  may  interfere  with  the  perfect  action  of  the  abdom- 
inal muscles  during  the  expulsive  stage  of  labor.  Frequently,  how- 
ever, adhesive  inflammation  causes  the  ovary  to  remain  within  the 
pelvic  excavation ;  or  it  may  have  been  prevented  from  ascending  into 
the  abdominal  cavity  by  the  gravid  uterus  having  already  occupied 
that  space ;  in  either  of  which  instances,  if  the  female  arrives  at  the 
full  term  of  utero-gestation,  the  labor  must  be  exceedingly  difficult, 
depending,  however,  on  the  size  and  character  of  the  tumor. 

The  diagnosis  of  an  ovarian  tumor,  at  the  period  of  labor,  is  not 
always  an  easy  matter.  It  will  be  found  external  to  the  vaginal  coats, 
commonly  toward  the  posterior  part  of  the  pelvis,  within  the  recto- 
vaginal  septum,  will  be  more  or  less  movable,  elastic,  and  fluctuating, 
or  hard  and  apparently  solid,  with  some  degree  of  sensibility.  The 
dropsical  tumor  presents  a  round,  smooth,  and  polished  surface,  while 
the  scirrhus  one  presents  nodules  and  irregularities.  It  is  proper  to 
examine  in  these  cases  both  by  vagina  and  rectum  simultaneously,,  for 
the  purpose  of  more  clearly  determining  them  from  vaginal  or  uterine 
tumors. 

TREATMENT. — In  the  management  of  these  cases,  much  will 
depend  upon  the  size  and  character  of  the  tumor,  bearing  in  mind 
that  these  tumors  are  "  more  likely  to  be  moved  out  of  the  way  of 
the  child  at  the  time  of  labor,  than  any  other,  and  also  more  apt  to 
give  way  and  burst  under  the  pressure  of  the  head." — (Churchill.} 
If  the  tumor  be  detected  previous  to  the  engagement  of  the  head  at 


40G  KING'S  ECLECTIC  OBSTETRICS. 

the  superior  strait,  and  it  is  movable,  attempts  should  be  made  to  push 
it  up  above  this  strait  by  steady  pressure,  so  as  to  place  it  beyond  the 
head.  If  this  can  not  be  accomplished,  we  must  rely  upon  the  natural 
powers,  until  the  symptoms  demand  our  interference.  If  the  tumor 
be  soft,  it  may  be  flattened,  or  ruptured,  and  thus  allow  the  head  to 
advance;  if  it  be  solid,  we  certainly  should  not  interfere  until  we  are 
compelled  to.  When  the  removal  of  the  obstacle  can  not  be  accom- 
plished, and  interference  is  called  for,  it  is  recommended  to  puncture 
the  tumor  by  means  of  a  trocar,  and  evacutate  the  fluid ;  and  if  the 
contents  of  the  tumor  be  viscid,  or  gelatinous,  not  passing  readily 
through  the  canula,  or  if  the  tumor  be  formed  of  numerous  cysts,  not 
communicating  with  each  other,  the  opening  must  be  enlarged  by 
making  an  incision  into  the  tumor  of  half  an  inch  or  an  inch  in 
extent.  When  the  tumor  is  located  between  the  sacrum  and  rectum, 
it  is  recommended  to  make  the  puncture  through  the  rectum ;  but  in 
other  instances  through  the  vagina,  as  there  is  less  danger  from  hem- 
orrhage from  the  vaginal  blood-vessels.  Should  a  fibrous  or  polypus 
tumor  be  punctured,  from  an  error  in  diagnosis,  no  great  harm  will  be 
done.  Great  care,  however,  must  be  exercised  in  the  examination  of 
fluctuating  tumors,  especially  when  they  are  toward  the  pubic  side  of 
the  pelvis,  as  the  bladder  may  prolapse  and  present  a  fluctuating  tumor,, 
and  which  must  not  be  punctured  under  ordinary  circumstances. 

If  the  tumor  be  solid,  and  can  not  be  pushed  up  above  the  brim,  or 
if  the  means  previously  employed  fail  to  lessen  its  size,  the  delivery 
should  be  effected  by  the  forceps,  in  all  cases  where  it  is  possible;  but 
where  this  can  not  be  done,  the  only  resource  left  is  embryotomy, 
extracting  the  brain,  and,  if  required,  the  contents  of  the  chest  and 
abdomen ;  unless,  indeed,  the  physician  is  willing  to  subject  the  mother 
to  'the  hazard  of  the  Cesarean  operation,  or  the  extirpation  of  the  dis- 
eased mass. 

Dr.  Merriman  has  recorded  the  history  of  eighteen  cases  of  ovarian 
tumors  impeding  labor,  in  which  nine  mothers  died,  three  recovered 
very  imperfectly,  and  six  escaped ;  of  the  children,  fifteen  were  still- 
born, and  three  were  born  alive.  He  states :  "  Twice,  the  labor  was 
effected  by  the  pains,  unassisted  by  the  art  of  the  accoucheur  ;  but  one 
of  these  women  lost  her  life,  and  one  of  the  children  was  still-born. 
Five  times  the  perforator  was  used,  after  a  longer  or  shorter  duration 
of  labor:  three  of  these  women  died,  another  recovered  very  imper- 
fectly, and  one  got  well.  Five  times  the  labor  was  terminated  by  turn- 
ing the  child  ;  all  the  children  were  lost,  and  only  one  mother  recovered.. 
Three  times,  the  tumors  having  been  opened,  the  labor  was  afterward 


DIFFICULT  LABOIJ — 7ItOM   MAL- POSITION*  OF  THE*  HEAD,  ETC.     4»>7 

trusted  to  nature ;  two  of  these  women  recovered,  but  the  other  re- 
mained for  a  long  time  in  an  ill  stale  of  health  ;  two  only  of  the 
children  were  preserved.  In  three  cases,  the  tumors  having  been 
opened,  it  was  still  found  necessary  to  have  recourse  to  the  perforator; 
one  of  these  women  died,  one  remained  in  an  Ul  state  of  health  for 
eighteen  months,  and  then  sank  under  her  sufferings;  the  third  re- 
covered. "  "  Upon  the  whole,"  Dr.  Merriman  observes,  "  the  evidence 
we  at  present  possess,  is  more  in  favor  of  opening  the  tumors  when 
they  contain  a  fluid,  than  of  any  other  mode  of  procedure ;  for  of  the 
nine  women  who  recovered  more  or  less  perfectly,  five  appear  to  owe 
their  safety  to  this  operation,  and  of  the  children  born  alive,  two  were 
preserved  by  the  same  means." 

In  all  these  case.s,  the  time  of  the  operation  must  be  determined  by 
the  constitutional  symptoms,  never  delaying  assistance  after  symptoms 
of  powerless  labor  have  commenced.  The  danger,  in  these  tumors, 
arises,  not  so  much  from  the  obstruction  to  the  labor,  as  from  the 
influence  exerted  upon  the  disease  itself;  the  pressure  upon  the  tumor, 
and  its  consequent  irritation,  together  with  the  debility,  or  exhaustion 
of  the  patient,  occasioned  by  the  prolonged  and  painful  parturition, 
render  her  unable  to  sustain  the  effects  of  the  irritation  and  nervous 
shock  after  the  conclusion  of  the  labor. 


CHAPTER   XXXII. 

ON    DIFFICULT    LABOR     FROM     FAULTY    CONDITIONS    OF    THE    CHILD, 
MAL-POSITION    OF    THE    HEAD,    ETC. 

OF  the  faulty  conditions  of  the  child  or  its  appendages,  that  may 
occasion  a  protracted  labor  in  the  second  stage,  are : 

1.— SHORTNESS  OF  THE  UMBILICAL  CORD.— It  may  be 

very  short,  naturally,  not  exceeding  six  or  seven  inches  in  length,  so 
that  it  becomes  torn  as  the  trunk  and  inferior  extremities  are  expelled, 
or  its  ligation  and  division  may  be  required  before  these  can  be 
extracted.  Most  commonly,  however,  the  shortness  of  the  cord  is 
accidental,  occasioned  by  its  being  twisted  several  times  round  the 
neck  or  body  of  the  fetus.  The  delay  in  the  progress  of  the  labor 
may  be  suspected  to  depend  upon  this  difficulty,  when  in  either  stage  of 
labor,  the  head  not  only  retracts  upon  the  subsidence  of  the  pain,  but 
does  not  advance  with  the  usual  force  when  the  pain  is  present ;  some- 


408  KING'S  ECLECTIC  ORSTETRICS. 

times  the  cord  may  be  so  shortened,  and  the  head  held  up  so  high,  as 
to  prevent  the  practitioner  from  ascertaining  the  presenting  part  until 
the  commencement  of  the  second  stage.  Should  the  placenta  he 
attached  to  some  portion  of  the  uterine  cavity,  near  the  neck,  instead 
of  toward  the  fundus,  the  above  symptoms  will  be  absent,  and  the 
diagnosis  will  be  very  obscure.  But  to  whatever  part  it  may  he 
attached,  a  sensation  of  dragging,  or  tearing,  with  pain,  will  be 
experienced  by  the  patient  during  the  expulsive  contractions,  when- 
ever the  cord  is  shortened. 

Should  the  case  be  suspected  a  shoulder  presentation,  from  the  fact 
that  at  the  full  dilatation  of  the  os  uteri,  the  presenting  part  can  not 
be  felt,  the  practitioner  may  be  induced  to  attempt  turning,  but  the 
introduction  of  the  hand  within  the  uterine  cavity,  at  once  ascertains 
the  presentation  of  the  head  retained  by  a  short  cord.  When,  in  the 
second  stage,  the  head  presents  in  a  proper  position,  and  is  of  normal 
size,  the  soft  parts  being  free  from  any  rigidity,  the  head  in  any  part 
of  the  pelvic  cavity,  and  the  pains  regular,  shortness  of  the  cord  may 
be  suspected  when  the  head  is  found  to  recede  very  much  with  the 
cessation  of  the  pains,  and  making  no  further  advance  when  they  are 
on,  for  several  hours  in  succession.  If  two  fingers,  or  even  the  whole 
hand,  be  passed  up  as  high  as  possible,  between  the  head  and  symphysis 
pubis,  the  diagnosis  will  be  positive,  upon  feeling  the  cord  passing 
around  the  neck. 

TREATMENT. — If  the  pulsations  in  the  cord  be  strong  and  vigor- 
ous, the  best  practice  is  to  have  patience,  and  leave  the  case  to  nature. 
If  the  pulsations  are  feeble,  or  gradually  becoming  so,  we  are  recom- 
mended by  Dr.  Lee  to  deliver  immediately  with  the  forceps,  and  to 
carefully  abstain  from  the  use  of  Ergot.  To  attempt  turning,  in  such 
a  case,  would  be  downright  stupidity. 

Prof.  Meigs  recommends  loosening  the  cord  by  pulling  upon  its 
yielding  end,  and  endeavoring  to  cast  it  off  over  the  head.  "This," 
he  says,  "  can  not  always  be  done ;  if  so,  in  any  case,  let  the  child  pass 
through  it  by  slipping  if  down  along  its  body  over  the  shoulders.  If 
it  seems  impossible  to  slip  the  cord  over  the  head  or  shoulders  either, 
it  should  be  let  alone;  and  in  a  great  majority  of  cases  it  will  not 
prevent  the  birth  from  taking  place,  after  which,  the  cord  can  be  cast 
off.  Should  the  child  seem  to  be  detained  by  the  tightness  of  the  cord, 
as  does  rarely  happen,  or  in  danger  from  the  compression  of  its  jugular 
vessels,  the  fun  is  may  be  cut  with  the  scissors,  and  tied  after  the 
delivery.  Under  such  a  necessity  as  this,  a  due  respect  for  one's  own 
reputation  should  induce  him  to  explain  to  the  bystanders  the  reasons 


DIFFICULT  LABOR — FROM  MAL-PORITIOX  OF  THE   HEAD,  ETC.     409 

which  rendered  so  considerable  a  departure  from  the  ordinary  practice 
indispensable."  In  the  event  of  considerable  hemorrhage,  it  would 
probably  be  judicious  to  place  a  ligature  on  the  umbilical  side  of  the 
severed  cord.  It  is  not  always,  however,  that  the  cord  can  be 
reached,  at  least  so  as  to  pull  it  down,  or  otherwise  operate  upon  it, 
and  in  such  instances  we  m.ist  expect  the  means  recommended  by 
Prof.  M.  to  be  impracticable.  Should  tha  child  be  dead,  as  ascer- 
tained by  absence  of  the  beating  of  the  fetal  heart,  and  the  cessation 
of  pulsation  in  the  cord,  the  labor  should  not  be  interfered  with. 

2.— HYDROCEPHALUS  is  occasionally  a  cause  of  difficult  la- 
bor ;  in  which  case,  notwithstanding  the  active  expulsory  pains  and 
the  dilatable  condition  of  the  os  uteri,  the  head  remains  above  the 
superior  strait,  and  if  the  cause  be  not  early  ascertained,  exhaustion, 
or  rupture  of  the  uterus  ensues.  The  danger  is  in  proportion  to  the 
size  of  the  child's  head  ;  where  the  effusion  is  inconsiderable,  the  soft 
and  flexible  condition  of  the  head  may  admit  of  its  delivery,  by 
gradually  adapting  it  to  the  canal  through  which  it  has  to  pass,  and 
lengthening  its  long  diameter  very  considerably.  But  when  the 
effusion  is  abundant,  and  the  diameters  of  the  head  exceed  those  of 
'the  pelvis  so  much  as  to  render  delivery  impossible,  interference 
will  be  demanded.  If  a  dropsical  head  be  allowed  to  remain  for 
any  time  impacted  in  the  pelvic  cavity,  the  continued  pressure  it 
exerts  upon  the  soft  parts  would  be  very  apt  to  produce  sloughing; 
and  in  nearly  all  those  cases,  where  the  cause  of  the  delay  has  not 
been  early  ascertained,  a  fatal  result  has  followed  to  both  the  mother 
and  child. 

A  hydrocephalic  head  may  be  detected  by  the  extraordinary  size  of 
the  head,  and  the  great  separation  of  its  bones,  by  which  the  sutures 
are  enlarged  to  the  size  of  a  finger,  or  more  in  breadth,  and  the  fon- 
tanelles  being  also  augmented,  at  times,  to  an  extent  equal  to  the 
hollow  of  the  hand.  The  cranial  bones  are  thin  and  softer  than  usual, 
and,  likewise,  during  the  pains,  a  sense  of  fluctuation  will  be  per- 
ceived in  some  places,  though  this  sensation  may  not  frequently  be 
observed,  owing  to  the  great  compression  the  head  undergoes.  In 
nates  or  feet  presentations  the  diagnosis  is  extremely  difficult ;  the 
child's  limbs  are  usually  shrunken  and  wasted,  and  descend  into  the 
pelvic  cavity  until  *the  head  is  -about  to  engage  at  the  brim,  when, 
notwithstanding  strong  and  continuous  pains,  any  farther  advance 
toward  delivery  is  suddenly  and  persistently  arrested.  In  cases  where 
hydrocephalus  is  suspected,  we  should  be  very  careful  to  obtain  ail 
accurate  diagnosis  lest  we  perforate  the  head  of  a  healthy  child. 


410  KING'S  ECLECTIC  OBSTETRICS. 

TREATMENT. — But  one  course  is  to  be  pursued  in  a  difficulty  of 
this  kind,  when  we  are  certain  that  the  head  can  not  be  delivered 
naturally,  or  without  endangering  sloughing  of  the  maternal  soft 
parts,  and  when  we  are  also  positive  that  hydrocephalus  is  pre.-ent. 
The  necessity  for  being  enabled  to  detect  presenting  parts,  as  well  as 
their  condition,  is  fully  shown  in  a  case  of  hydrocephalus;  for  should 
a  careless  or  ignorant  practitioner  neglect  to  ascertain  the  positive  con- 
ditions present  in  a  difficult  labor  owing  to  this  cause,  and  administer 
Ergot,  or  other  agents,  to  excite  energetic  contractions  of  the  uterus,  he 
would  be  very  apt  to  occasion  a  rupture  of  this  organ  ;  or  should  the 
head  be  expelled,  it  would  be  at  the  hazard  of  the  mother's  life,  from 
sloughing. 

In  hydrocephalus,  where  the  head  can  not  be  delivered  by  the 
natural  powers,  the  best  chance  for  the  mother's  safety  is,  to  evacuate 
the  effused  fluid  by  puncturing  with  the  perforator  at  an  early  period, 
while  she  has  sufficient  strength  and  vigor  to  withstand  the  shock  ;  if 
the  operation  be  delayed  too  long,  she  may  die  from  rupture  of  the 
uterus,  or  from  exhaustion.  Cases  are  on  record  in  which  the  accu- 
mulation was  external  to  the  cranial  cavity,  and  it  may  likewise  be 
lodged  immediately  within  the  cranium;  consequently  the  puncture 
should  be  guarded,  in  the  hope  of  evacuating  the  fluid  without  dis- 
turbing the  cerebral  structure,  and  saving  the  life  of  the  child.  After 
the  evacuation  of  the  fluid,  the  collapse  of  the  bones  will  permit  the 
labor  to  be  terminated  by  the  uterine  contractions  alone ;  and  if  these 
fail,  means  may  be  employed  to  excite  them  into  greater  activity,  or 
the  forceps  may  be  demanded.  Hydrocephalus  is  not  always  readily 
detected  during  labor,  and  when  it  is  the  discovery  is  usually  too 
late  for  the  mother  to  derive  any  advantage  from  it,  as  it  alniQst 
always  terminates  fatally.  It  is  very  rarely  the  case  that  the  paiu.< 
occasion  a  rupture  of  the  head,  with  escape  of  the  fluid,  and  delivery 
— but  we  must  never  wait  for  this  result  after  having  made  our 
diagnosis. 

Should  the  case  be  one  of  pelvic  presentation,  and  the  head  delayed 
from  disproportion,  the  perforation  must  be  made  behind  the  ears;  or, 
as  has  been  suggested  by  Dr.  J.  Simpson,  the  fluid  may  be  permitted 
to  escape"  by  opening  any  part  of  the  vertebral  canal;  or  the  cranial 
cavity  may  be  reached  by  perforating  the  base  of  the  skull  through 
the  roof  of  the  mouth.  • 

Sometimes  Ascites,  or  Dropsy  of  the  Abdomen,  may  prevent  the 
body  of  the  child  from  being  expelled ;  or  this  may  occur  from 


DIFFICULT  LABOR — FROM   MAL-POSITION  OF  THE  HEAD,  ETC.     411 

Tympanitis,  or  a  Distension  of  the  Abdomen  with  air ;  in  these  cases, 
the  perforator  must  be  thrust  into  the  child's  body,  and  the  air  or  fluid 
evacuated. 

3.— Difficult  Labor  may  arise  from  TOO  EARLY  A  DEPAR- 
TURE OF  THE  CHIN  FROM  THE  BREAST— cm  Abnormal, 
or  Premature  Extension  of  the  Head — giving  rise  to  the  Brow  Presen- 
tations of  some  authors.  The  nearer  to  the  center  of  the  pelvic  cavity 
we  find  the  posterior  fontanelle,  the  greater  will  be  the  flexion  of  the 
head,  and  the  more  readily  will  it  advance;  and  the  nearer  to  the  walls 
of  the  pelvic  cavity  we  find  this  fontanelle,  the  greater  will  be  the 
abnormal  extension,  or  the  departure  of  the  chin  from  the  breast,  and 
the  more  slowly  will  labor  progress ;  it  is  an  excess  of  this  departure 
which  gives  rise  to  face  presentations. 

In  all  normal  vertex  presentations  the  posterior  fontanelle  should 
be  down  toward  the  axis  of  the  pelvic  cavity,  nearly  in  approximation 
with  it ;  but  in  proportion  as  it  recedes  from  this  point,  and  approxi- 
mates toward  the  side  of  the  pelvis,  will  the  anterior  fontanelle  be 
brought  toward  the  center  of  the  excavation.  And  at  an  early  stage 
of  the  labor,  this  abnormal  position  may  loe  known  by  finding  this 
latter  fontanelle  near  the  center  of  the  pelvis;  but,  if  the  head  should 
have  advanced  as  far  as  the  inferior  strait,  one  of  the  parietal  pro- 
tuberances will  be  at  or  near  the  pubic  arch,  while  the  anterior  fonta- 
nelle will  be  found  looking  toward  the  inner  perineal  surface. 

TREATMENT.— In  a  difficulty  of  this  kind,  the  labor  will  speedily 
be  finished,  after  having  restored  the  flexion.  To  accomplish  this, 
two  modes  are  advised;  the  first  is  to  be  performed  when  the  head 
has  not  entirely  passed  the  superior  strait,  the  os  uteri  being  well 
dilated,  the  membranes  ruptured,  and  the  pains  sufficiently  energetic. 
And,  when  possible,  it  is  always  better  to  effect  the  adjustment  at  this 
period,  than  when  the  head  has  completely  passed  through  the  superior 
strait.  Should  any  obliquity  of  the  uterus  exist,  it  must  first  be 
removed,  according  to  the  preceding  directions;  then  introduce 
two  or  three  fingers  into  the  vagina,  and,  during  the  absence  of 
pain,  slightly  elevate  the  forehead  and  hold  it  thus,  supported  by  the 
fingers  during  one  or  more  pains,  until  the  vertex  is  found  to  descend, 
and  the  forehead  to  apparently  ascend,  when  the  fingers  may  be  with- 
drawn, and  the  case  left  to  the  natural  powers.  The  object  of  the 
operation  is  not  to  push  the  anterior  fontanelle  above  the  superior 
strait,  which  will  be  found  a  difficult  task,  but  to  make  counter- 
pressure  during  a  pain,  to  prevent  it  from  descending  any  further, 


412  KING'S  ECLECTIC  OBSTKTIIICS. 

thus  allowing  the  vertex,  or  occiput  to  descend  with  the  expulsive 
efforts  of  the  uterus,  and  which  descent  will  restore  the  normal  flexion 
of  the  head.  It  may  sometimes  require  the  introduction  of  the  whole 
hand,  to  effect  this  change.  In  performing  this  operation,  the  practi- 
tioner  should  be  careful  not  to  make  any  pressure  upon  the  anterior 
fontanelle  itself,  but  only  in  its  neighborhood. 

The  second  mode  of  operating  is  to  be  pursued  when  the  head  is 
•completely  in  the  excavation.  The  fingers,  or  half  of  the  hand,  if 
necessary,  must  be  introduced  into  the  vagina,  and  perhaps,  also, 
within  the  cervix,  so  as  to  grasp  the  posterior-superior  portion  of  the 
head,  and  during  the  absence  of  a  pain,  the  head  should  be  directed, 
or  pressed  in  such  a  manner  as  to  bring  its  anterior  portion  against 
that  part  of  the  pelvic  wall  facing  it,  while  at  the  same  time  the 
fingers  should  obtain  a  purchase  on  the  edge  of  the  parietal  bones, 
formed  by  the  gliding  of'  the  occipital  bone  under  them,  and  carefully 
pull  the  vertex  down  toward  the  center  of  the  pelvis;  this  accom- 
plished, the  vertex  should  be  retained  thus,  until  a  subsequent  pain 
renders  the  change  permanent.  Thus,  if  the  vertex  be  toward  the 
left  acetabulum,  the  head  will  be  pressed  toward  the  right  sacro-iliao 
symphysis,  while,  at  the  same  time,  the  vertex  is  pulled  downward. 
The  hand  to  be  introduced  in  this  operation  must  be  that,  the  palm 
of  which  is  directed  toward,  or  may  be  applied  upon,  the  vertex.  In 
cases  of  this  kind  but  little  could  be  accomplished  by  making  pressure 
upward,  with  the  fingers  upon  the  forehead,  besides  which,  the  upper 
edge  of  the  os  frontis  being  imperfectly  ossified,  the  force  required  to 
elevate  it  might  indent  the  yielding  bone,  and  produce  some  injury  to 
the  brain ;  hence  it  is  better  to  apply  the  power  to  the  more  perfectly 
ossified  posterior  edges  of  the  parietal  bones.  Sometimes,  but  very 
rarely,  a  vectis  will  be  required  to  effect  the  proper  adjustment  of  the 
head  when  in  the  pelvic  cavity. 

4. — It  was  remarked  in  the  Chapter  on  the  Mechanism  of  Labor; 
that  in  occipito-posterior  positions  of  the  head,  the  movement  of 
rotation  usually  changed  them  so  that  toward  the  latter  period  of 
labor,  the  occiput  became  placed  under  the  pubic  arch,  the  same  as 
if  the  positions  had  been  originally  oceipito-anterior.  Sometimes, 
however,  this  change  is  not  effected,  and  the  head  presents  at  the 
inferior  strait,  with  the  occiput  to  the  sacrum,  and  the  FOREHEAD 
TOWARD  THE  PUBIC  ARCH.  If  the  diameters  of  the  pelvis 
and  fetal  head  be  normal,  and  the  contractions  of  the  uterus  efficient, 
the  delivery  may  be  accomplished  without  any  interference;  the  head 


DIFFICULT  LABOR — FROM  MAL  POSITION  OF  THE  HEAD,  ETC.      413 

may  be  expelled  presenting  its  oecipito-frontal  diameter  to  the  antero- 
posterior  diameter  of  the  inferior  strait,  or  the  forehead  may  remain 
at  the  pubic  arch  until  the  posterior  part  of  the  head  has  passed  over 
the  perineum.  This  position  of  the  head,  notwithstanding  it  may  not 
interfere  with  a  safe  delivery,  may  be  considered  a  mal-position.  In 
29,684  cases  recorded  by  various  authors,  the  forehead  was  under  the 
pubic  arch  in  87,  or  about  1  in  342J ;  and  of  22  children  born  in  this 
position,  where  the  results  were  noted,  9  were  lost. 

As  remarked  above,  the  delivery  may  be  safely  accomplished  by 
the  natural  powers;  and  where  the  head  is  large,  or  the  pelvis  narrow, 
or  where  both  these  conditions  occur  at  the  same  time,  the  labor  will 
be  necessarily  protracted,  yet  the  child  may  be  born  without  any 
serious  consequences  to  its  mother  or  self.  But  where  the  pelvis  is 
considerably  narrower  than  usual,  the  aid  of  the  accoucheur  will 
undoubtedly  be  required. 

Cases  of  this  kind  maybe  ascertained  by  making  a  careful  examina- 
tion after  the  rupture  of  the  membranes ;  the  forehead  not  being  as 
round  as  the  occiput,  will  present  a  flatter  surface  which  does  not  fill 
up  the  pubic  arch,  the  anterior  fontanelle  will  be  found  toward  the 
pijbic  symphysis,  the  sagittal  suture  will  be  felt  passing  backward,  in 
the  direction  (nearly)  of  the  antero-posterior  diameter,  to  the  posterior 
fontanelle,  which  latter  will  be  toward  the  sacrum.  The  parietal 
bones  do  not  overlap  one  another  as  usual,  the  swelling  of  the  scalp 
forms  less  rapidly,  and  sometimes  the  finger  can  be  passed  up  behind 
the  symphysis  pubis  and  detect  the  eyes  and  root  of  the  nose.  If  the 
head  has  suifered  for  a  long  time  from  pressure  while  in  the  pelvis, 
there  may  be  some  difficulty  in  detecting  the  sagittal  suture  and 
posterior  fontanelle. 

TREATMENT. — "We  should  not  interfere  in  these  cases  as  long  as 
the  uterine  contractions  are  regular,  and  the  head  advances,  however 
slowly.  But  when  the  contractions  cease,  or  are  not  sufficient  to  cause 
any  advance  of  the  head,  a  careful  examination  of  the  parts  and  of 
the  fetal  head  must  be  made  to  ascertain  their  relative  proportions, 
and  such  aid  must  be  aiforded  as  the  circumstances  of  the  case  may 
require.  On  a  preceding  page  I  have  given  the  mode  of  manage- 
ment recommended  by  Dr.  Dewees  for  the  purpose  of  overcoming 
the  difficulty  under  consideration,  which  contemplates  the  anterior 
rotation  of  the  occiput;  the  uterus  being  fully  dilated,  the  mem- 
branes ruptured,  the  head  occupying  the  lower  strait,  and  the  labor 
active,  the  index  finger  is  to  be  placed  against  the  edge  of  the  sagit- 
tal suture,  either  before  or  behind  the  anterior  fontauelle,  and,  in  the 


414  KING'S  ECLECTIC  OUST  ETHICS. 

absence  of  a  pain,  the  part  is  to  be  pressed  toward  the  right  or  left 
.-acro-iliae  symphysis,  as  the  primary  position  would  indicate,  and 
held  steadily  during  the  subsequent  contraction  of  the  uterus,  reduc- 
ing a  fourth  to  a  first,  and  a  fifth  to  a  second  position.  But  although 
this  frequently  succeeds,  it  as  often  fails,  and  the  practitioner  will 
then  have  to  resort  to  the  forceps,  especially  where  there  is  a  failure  of 
uterine  power,  or  perhaps  the  perforator  may  be  demanded ;  of  course, 
the  period  for  operating  will  be  selected  according  to  the  degree  of 
the  difficulty,  and  the  symptoms  of  the  patient. 

Not  unfrequently,  in  occipito-posterior  positions,  there  may  be  a 
delay  in  the  descent  of  the  head,  before  it  has  reached  the  inferior 
strait.  The  membranes  having  ruptured,  the  expulsive  contractions 
are  found  to  cause  no  advance  of  the  head;  an  examination  will  detect 
the  posterior  fontanelle  toward  one  of  the  sacro-iliac  symphyses,  and 
the  sagittal  suture  may  be  traced  upward  and  forward  to  the  anterior 
fontanelle,  which  will  be  located  behind  the  opposite  acetabulum.  In 
cases  of  this  kind,  an  early  interference  is  improper,  the  practitioner 
should  wait  until  from  the  number  of  strong  pains,  he  is  satisfied  that 
they  are  unable  to  advance  the  head,  when,  for  the  purpose  of  ulti- 
mately bringing  the  occiput  under  the  pubic  arch,  he  may  grasp  the 
oranium  between  the  thumb  and  fingers,  during  the  absence  of  a  pain, 
and  move  the  face  toward  the  right  or  left  ilium,  according  as  it 
originally  presented  to  the  right  or  left  acetabulum;  being  careful  not 
to  carry  it  into  the  hollow  of  the  sacrum,  notwithstanding  the  readiness 
with  which  so  great  a  change  might  be  effected,  because,  should  the 
child's  body  fail  to  follow  the  rotation  given  to  the  head,  a  serious 
injury  to  the  neck  would,  very  probably,  be  the  result;  therefore,  after 
having  inclined  the  face  to  one  of  the  ilia,  the  rest  of  the  process  must 
be  left  to  nature.  Should  the  manipulation  fail,  the  face  returning  to 
its  original  position  with  the  pain,  it  may  be  repeated  several  times 
tmtil  it  succeeds.  Should  the  head  become  impacted  in  the  pelvic 
cavity  before  the  operation  is  attempted,  it  is  very  probable  that  the 
forceps  or  the  perforator,  will  be  required  to  terminate  the  delivery. 
(See  Occipito-Pubal  Position,  and  Occipito-Sacral  Position.] 

5.— As  a  general  rule,  FACE  PRESENTATIONS,  may  be  included 
among  natural  labors,  from  the  fact  that  they  commonly  terminate 
without  any  artificial  aid;  the  labors,  however,  are  very  tedious  and 
painful  to  the  mother,  and  occasion  considerable  distortion  of  the 
Child's  features.  They  are  now  correctly  considered  to  be  deviations 
from  a  head  or  vertex  presentation,  and  though  delivery,  in  the  greater 


DIFFICULT   LABOR FEOM  MAL-POSITIOX  OF  THE  HEAD,  ETC.  415 

number  of  instances,  is  effected  by  the  natural  powers,  still  they  should 
always  be  regarded  as  mal-positions. 

When  the  head  is  in  a  proper  state  of  flexion,  the  chin  touching  or 
approximating  toward  the  breast,  the  presentation  is  always  a  normal 
one  of  the  head,  but  if  there  is  a  premature  extension  or  departure  of 
the  chin  from  the  breast,  the  tendency  wrill  be  toward  a  face  presenta- 
tion, in  which  the  head  gradually  becomes  bent  backward  so  far  as  to 
ultimately  place  the  face  nearly  flat  across  the  oblique  diameter  of  the 
superior  strait,  looking  down  into  the  pelvis;  and  this  position  almost 
always  occasions  a  tedious  labor,  not  unfrequently  requiring  the  aid  of 
the  accoucheur. 

In  relation  to  the  cause  of  the  difficulty  in  this  presentation,  Prof. 
Meigs  remarks:  "The  fetal  head  being  an  oval,  five  inches  long,  from 
the  vertex  to  the  chin,  and  more  than  three  and  a  half  inches  wide  at 
the  widest  part,  it  ought  to  make  no  difference,  as  far  as  the  mere  head 
is  concerned,  whether  the  chin  or  the  vertex  advances  first  in  labor, 
because,  in  either  case,  the  same  circumferences  of  the  head  are  pre- 
sented to  the  planes  through  which  they  are  to  be  transmitted.  The 
foramen  magnum  of  the  occipital  bone  being  equidistant  from  the 
vertex  and  chin,  and  situated  on  one  side  of  the  oval,  the  peculiar 
difficulties  and  hazards  of  these  labors  are  attributable,  rather  to  the 
nature  of  the  articulation  by  which  the  neck  and  head  are  conjoined, 
than  to  the  form  of  the  head  itself,  when  advancing  with  the  face 
downward.  The  nature  of  this  articulation  is  such,  that  extension  of 
the  head  can  not  take  place  so  well  as  flexion ;  hence  the  requisite 
dip  of  the  occipito-frontal  diameter  is  not  effected  in  face  cases  without 
difficulty,  and  the  consumption  of  much  time. 

"  Let  the  reader  figure  to  himself  the  state  of  the  spinal  column  cf 
a  child,  urged  on  in  labor  by  powerful  uterine  contractions,  directed 
to  its  expulsion  with  the  face  in  advance.  The  inferior-posterior  part 
of  the  head  is  pressed  against  the  back  of  its  neck,  or  between  its 
scapulas,  which  could  not  be  the  case  without  bending  the  cervical 
spine  backward,  like  a  bow,  while  the  dorsal  and  lumbar  vertebras  are 
curved  in  the  opposite  direction,  causing  thus  a  double  antero- posterior 
curve,  on  which,  in  consequence  of  the  elasticity  of  the  two  arches, 
much  of  the  expulsive  force  is  vainly  expended ;  so  that,  though  the 
power  may  be  as  great  as  in  a  common  labor,  it  produces  much  less 
effect  than  in  a  common  labor — a  great  part  of  every  pain  being 
expended  in  reproducing  the  greatest  amount  of  curvature :  for  the 
elasticity  of  the  two  curves  is  such  that  they  are  straightened  as  soon 
as  the  pains  subside,  at  least  in  some  measure,  while  the  rest  of  the 


KI.MJ'.S    ECLECTIC    OBSTETRICS. 

pain  is  used  in  pushing  the  face  onward."  These  remarks  of  Prof. 
Meigs  are  undoubtedly  correct,  and  should  be  constantly  kept  in  view 
during  a  labor  of  the  kind  under  consideration. 

Face  presentations  are  usually  forehead  presentations  at  first,  in 
which  there  .is  a  departure  of  the  chin  from  the  breast  at  an  early 
period  of  labor,  and  an  examination  at  tbis  time,  when  the  forehead 
presents,  may  mislead  the  practitioner,  who,  feeling  the  firm,  globular 
presenting  brow,  rests  satisfied  that  it  is  a  head  case,  and  only  discovers 
his  error  when  the  labor  has  too  far  advanced  for  successful  inter- 
ference. In  these  cases,  it  must  be  remembered  that  the  forehead 
presents  first ;  and  as  the  uterine  contractions  continue,  extension  of 
the  head  gradually  progresses,  so  that  one  eye,  then  the  other,  the  nose, 
the  mouth,  and  the  chin,  are  successively  placed  within  reach  of  the 
finger.  Instances  have  been  met  with,  however,  where  the  face 
originally  presented  at  the  brim. 

The  cause  of  presentation  of  the  face  is  not  satisfactorily  understood; 
the  most  common  belief  is,  that  it  is  owing  to  uterine  obliquity.  For 
instance,  if  the  obliquity  carries  the  fundus  far  down  on  the  right  side, 
the  vertex,  instead  of  presenting  in  the  direction  of  the  axis  of  the 
brim,  will  present  at  a  greater  or  less  degree  of  inclination  to  it,  and 
the  expulsive  contractions  of  the  uterus,  acting  in  the  direction  of  its 
longitudinal  axis,  will  force  the  fetus  from  above  downward,  and  from 
right  to  left,  so  that  the  vertex  will  be  made  to  glance  upward  into 
the  left  iliac  fossa,  and  a  shoulder  be  presented  at  the  brim,  or,  the 
vertex  being  arrested  at  the  left  border  of  the  superior  strait,  the 
forehead  will  present,  extension  will  gradually  be  produced  by  the 
continuance  of  the  pains,  .and  the  head  be  forced  backward  upon  the 
child's  back.  This  is,  probably,  the  cause  of  the  major  number  of 
these  presentations,  yet  they  are  sometimes,  met  with  where  there  is  no 
obliquity  present,  and  it  is  very  difficult  to  assign  any  correct  reasons 
for  their  occurrence.  Labor  coming  on  before  the  position  of  the  fetus 
is  normally  established,  as  in  case  of  premature  rupture  of  the  mem- 
branes, etc.,  and  excessive  coughing,  have  been  named  among  the 
causes,  and  may  occasionally  effect  a  change  in  the  position  of  the  fetal 
head ;  but  where  a  face  position  is  a  primitive  presentation,  we  have  no 
satisfactory  idea  of  its  origination. 

DIAGNOSIS. — If  the  examination  be  made  at  an  early  period  of 
labor,  before  the  membranes  are  ruptured,  it  will  be  very  difficult  to 
ascertain  the  character  of  the  presentation,  from  the  fact  that  the  fore- 
head, which  only  presents  at  that  time,  may  readily  be  mistaken  for  a 
vertex  position.  But  after  the  extension  of  the  head  is  completed,  and 


DIFFICULT  LABOR — FEOM  MAL-POSITIOX  OF  THE  HEAD,  ETC.    417 

the  membranes  have  ruptured,  the  diagnosis  becomes  more  easy :  on 
one  side  of  the  pelvis  we  find  the  forehead  imparting  the  sensation  of 
a  rounded,  solid  surface,  through  which  the  anterior  portion  of  the 
sagittal  suture  may  be  felt  traversing;  carrying  the  finger  slowly  along 
to  the  opposite  side,  in  the  median  line,  it  meets  with  a  triangular 
elevation,  increasing  in  size  as  it  leaves  the  forehead,  and  crossing  the 
pelvis  somewhat  obliquely,  and  which  is  the  nose;  at  its  base  will  be 
found  two  small  openings,  the  nares,  which  always  look  toward  that 
portion  of  the  pelvis  where  the  chin  is  situated,  and  which  consequently 
afford  great  aid  in  determining  the  position.  On  either  side  of  this 
triangular  protuberance,  at  its  apex,  the  eyes  will  be  felt  as  two  soft 
tumors,  surrounded  by  a  circle  of  bone ;  and  the  examination  should 
be  gently  and  carefully  conducted,  lest  the  eyes  become  seriously 
injured  or  even  destroyed.  A  short  distance  from  the  base  of  the  nose 
will  be  found  the  mouth,  conveying  the  sensation  of  a  transverse 
fissure  bounded  by  the  superior  and  inferior  maxillary  arches.  At  the 
commencement  of  labor,  in  a  face  presentation,  the  mouth  is,  as  it 
were,  substituted  for  the  anterior  fontanelle,  the  nasal  bridge  for  the 
sagittal  suture,  and  the  orbital  ridges,  according  to  the  position,  for 
the  coronal  or  lambdoidal  suture.  As  the  face  does  not  look  directly 
downward,  but  presents  with  one  cheek  more  dependent  than  the- 
other,  the  malar  bone  and  eye  of  the  dependent  part  will  be  the  first 
points  with  which  the  examining  finger  will  come  in  contact. 

If  a  long  time  has  elapsed  after  the  rupture  of  the  membranes, 
before  the  delay  in  the  labor  induces  the  accoucheur  to  make  a  more 
careful  examination,  the  diagnosis  will  be  more  difficult;  hence  the 
necessity  for  making  a  thorough  examination  immediately  or  very 
soon  after  their  rapture,  in  all  cases  of  labor.  The  tedious  progress 
of  the  head,  and  the  compression  which  it  undergoes,  cause  the  face 
to  become  very  much  tumefied  ;  the  cheeks  being  greatly  swollen  and 
at  the  same  time  pressed  toward  each  other,  a  fissure  is  formed  between 
them,  in  which  the  diagnostic  characters  of  the  face  are  concealed,  and 
which  might  lead  the  practitioner  to  confound  them  with  the  nates  and 
their  intervening  fissure.  The  lips  also  swell,  become  wrinkled,  and 
turn  in,  presenting  a  rounded  orifice  instead  of  the  usual  transverse 
fissure,  and  which  has  been  mistaken  for  the  anus,  but  which  may  be 
at  once  known  by  introducing  the  finger  into  it,  and  feeling  the  tongue 
and  alveolar  processes. 

"Whenever  a  case  of  face  presentation  is  met  with,  it  should  be  an- 
nounced to  the  friends  of  the  patient,  together  with  the  probability  of 
27 


418  KING'S  ECLECTIC  OBSTETRICS. 

considerable  distortion  of  the  features  of  the  child  when  born,  else  its 
frightful  appearance  may  be  attributed  to  some  improper  violence,  or 
perhaps  want  of  skill,  on  the  part  of  the  medical  attendant.  If  the 
labor  is  a  tedious  one,  the  appearance  of  the  new-born  child  will  be 
very  repulsive,  its  face  swollen,  the  eyelids  in  a  tumefied  state,  and 
one  or  both  eyes  closed,  the  nose  also  swollen  to  an  enormous  extent, 
and  the  whole  features  presenting  a  dark  or  livid  appearance,  scarcely 
being  recognized  as  the  countenance  of  a  human  being.  These  ap- 
pearances generally  pass  off  in  a  few  days.  Sometimes,  when  the  labor 
is  very  tedious,  the  congestion  or  stasis  of  the  blood  extends  even  to 
the  brain,  creating  an  apoplectic  condition,  and  occasionally  the  death 
of  the  child. 

Although  the  face  may  present  in  various  positions,  yet  for  practical 
purposes,  the  two  heretofore  named  are  all-sufficient,  viz.:  the  left 
mento-iliac,  and  the  right  mento-iliac.  And  these  names  will  apply  to 
the  positions  when  the  chin  is  to  the  left  or  right  side  of  the  pelvis, 
whether  they  be  directly  transverse,  as  more  frequently  happens,  or 
have  the  chin  turned  more  0r  less  anteriorly  near  the  body  of  the 
pubic  bone,  or  posteriorly  toward  the  sacro-iliac  symphysis.  So  that, 
for  instance,  should  the  face  be  placed  in  the  pelvis  exactly  in  a  trans- 
verse position,  with  the  chin  to  the  right  ilium,  or  obliquely  with  the 
chin  toward  the  right  sacro-iliac  symphysis,  or  toward  the  right  pubic 
bone,  the  obliquity  of  the  position  does  not,  in  either  case,  interfere 
with  its  claim  as  a  right  mento-iliac  position ;  and  so  of  the  left,  when 
the  chin  is  placed  at  the  left  side  of  rhe  pelvis.  The  transverse  posi- 
tions of  face  cases  being  the  most  frequent,  are  regarded  as  the  primitive 
positions,  from  which  the  oblique  positions  are  derived  during  the 
progress  of  labor. 

A.— MECHANISM  OF  LEFT  MENTO-ILIAC  POSITION. 

This  position  is  not  so  frequent  as  the  right  mento-iliac,  and  is 
usually  termed  the  second  position  ;  but  for  the  purpose  of  preserving 
regularity,  and  aiding  the  student  in  recollecting  all  positions,  as  being 
successively  to  the  left,  right,  and  front,  I  have  given  it  as  the  first 
position.  As  a  general  rule,  previous  to  the  rupture  of  the  membranes, 
the  forehead  will  be  found  near  the  center  of  the  superior  strait,  the 
chin  being  placed  at  the  left,  and  the  anterior  fontanelle  at  the  right 
side  of  the  pelvis.  The  mento-bregmatic  diameter  of  the  fetal  head 
corresponds  to  the  transverse  diameter  of  the  upper  pelvis,  the  bi- 


FIG.  56. 


DIFFICULT  LABOR FROM  MAL-POSITION  OF   THE  HEAD,  ETC.    419 

temporal  of  the  former  to  the  antero-posterior  of  the  latter,  and  the 
occipito-frontal  diameter  of  the  head  is  in  a  direction  with  the  axis  of 
the  superior  strait.  The  back  of  the  child  is  toward  the  right  side  of 
the  mother,  and  its  abdomen  toward  her  left  side ;  its  left  side  is  in 
front,  and  its  right  behind ;  the  feet  are  above  and  to  the  left.  (Fig. 
56.)  (Figures  56,  57,  and  58,  represent  the  right  mento-iliac  positions, 
•but  as  far  as  the  mechanism  of  labor  is  concerned,  they  ivill  answer  to 
illustrate  the  left  mento-iliac  positions.] 

As  soon  as  the  membranes  rupture, 
:and  the  expulsive  contractions  com- 
mence, the  head  being  in  a  state  of 
moderate  extension,  and  meeting  with 
resistance,  forced  extension  takes  place, 
which  gradually  causes  the  face  to 
present  at  the  superior  strait  instead 
of  the  forehead,  as  heretofore  ex- 
plained. The  fronto-mental  diameter 
•of  the  head  now  corresponds,  instead 
of  the  mento-bregmatic,  to  the  trans- 
verse diameter  of  the  brim ;  the  bi- 
temporal  to  the  antero-posterior,  and 
the  fronto-mental  circumference  offers 

to  that  of  the  superior  strait;  the  body  of  the  child  remains  unchanged, 
and  a  line  drawn  from  the  upper  lip  of  the  child  to  the  posterior 
fontanelle,  will  give  the  direction  of  the  axis  of  the  upper  strait. 

(Fig.  57.)  As  soon  as  the  extension 
of  the  head  is  completed,  it  engages  in 
the  pelvic  cavity  and  descends  as  low 
as  possible,  or  as  far  as  the  length  of 
its  neck  will  permit.  The  depth  of 
the  lateral  part  of  the  pelvis  is  three 
inches,  and  as  the  length  of  the  neck 
does  not  reach  this  measurement,  the 
descent  of  the  head  is  limited,  and 
must  cease  at  some  point  short  of  the 
pelvic  floor;  for  if  it  advanced  further, 
the  head  and  part  of  the  child's  breast 
would  be  contained  in  the  pelvic  cavity 
at  the  same  time,  a  thing  not  ordin- 
arily possible.  The  resistance  of  the 
-soft  parts,  the  anterior  surface  of  the  spine  of  the  left  ischium  [which 


FIG.  57. 


420 


KING'S    ECLECTIC    OBSTETRICS. 


acts  upon  the  right  side  of  the  chin],  and  the  inclined  pelvic  planes- 
cause  the  head  to  rotate,  carrying  the  chin  from  left  to  right,  in  front 
and  behind  the  symphysis  pubis,  while  the  forehead  passes  from  right 
to  left,  backward  into  the  hollow  of  the  sacrum.  Should  the  chin  fail 
to  rotate  toward  the  symphysis  pubis,  the  labor  will  be  immensely 
difficult,  if  not  altogether  impossible,  because  the  oceipito-mental 
diameter  of  the  head  must,  toward  the  termination  of  the  process,  offer 
to  the  antero-posterior  of  the  inferior  strait,  or  nearly  so,  before  the 
head  can  be  born.  The  descent  and  rotation  of  the  head  being  now 
completed,  the  process  of  flexion  commences,  the  pains  push  the  body 
of  the  inferior  maxillary  bone,  and  finally  the  fore-part  of  the  neck 
against  the  posterior  surface  of  the  pubes,  which  arrests  its  progress,, 
and,  in  consequence  of  the  impossibility  of  any  further  descent  of  the 
neck,  the  expulsive  force  is  exerted  at  this  time,  principally  upon  the 
occiput,  and  the  head  is  gradually  delivered  by  successively  presenting 
at  the  vulva,  first  the  chin,  then  the  mouth,  nose,  eye.c,  forehead, 
anterior  fontanelle,  posterior  fontanelle,  and  occiput,  which  latter  has 
to  traverse  the  whole  anterior  sacral  surface,  a  distance  of  about  five 
inches  and  a  quarter;  and  during  the  delivery  the  perineum  becomes 
greatly  distended.  As  the  chin  emerges  under  the  pubic  arch,  there  is 
not  a  correspondence  of  the  whole  measurement  of  the  oceipito- 
mental  diameter  of  the  fetal  head  with  the  antero-posterior  diameter 
of  the  inferior  strait,  as  shown  in  the  linear  representation  of  the 
various  degrees  of  the  head's  disengagement,  in  Fig.  58,  in  which, 
while  the  head  is  in  the  same  position,  the  occiput  is  represented  as 
departing  more  and  more  from  the  shoul-  FIG  58. 

ders.  The  head  being  disengaged,  the 
motion  of  restitution  follows,  placing  the 
occiput  to  the.  right  side  qf  the  mother, 
and  which,  as  in  vertex  presentations,  is 
owing  to  the  rotation  of  the  shoulders  at 
the  lower  strait.  The  head  being  deliv- 
ered, the  expulsion  of  the  body  is  effected 
as  in  ordinary  vertex  positions.  It  must 
be  recollected,  that  in  this  position  the  left 
side  of  the  child's  face  is  anterior  and 
rather  more  depressed  than  the  other  side 
upon  entering  the  superior  strait,  and  on 
making  an  examination,  the  finger  comes  in  contact  with  the  left  eye 
or  malar  bone,  upon  which  part  is  formed  the  primary  tumor.  Nsege'le 
observes  that  the  swelling  forms  "first  upon  the  upper  part  of  the" 


DIFFICULT  LABOR — FROM  MAL-POSITION  OF  THE  HEAD,  ETC.    421 

left  "half  of  the  face,  which  in  this  species  of  a  face  presentation  (left 
mento-iliac)  is  always  situated  lowest."  "  If  the  progress  of  the  head 
through  the  external  passages  be  unusually  rapid,  this  is  the  only 
tumefaction  observed;  but  if  it  advances  slowly,  and  the  head  remains 
a  long  time  in  the  cavity  of  the  pelvis  before  it  actually  enters  the 
vagina,  the  inferior  half  of  the  left  side  of  the  face,  viz.:  part  of  the 
left  cheek,  will  be  remarked  after  birth  as  being  the  principal  seat  of 
the  swelling/'  a  secondary  tumor  being  formed  there.  * 

It  is  sometimes  the  case,  especially  when  the  chin  is  situated  rather 
posteriorly,  that  previous  to  the  movement  of  rotation  a  certain  degree 
of  flexion  takes  place,  which  causes  the  forehead  to  descend  to  the 
pelvic  floor,  after  which  the  chin  rotates  to  the  pubic  symphysis,  and 
the  delivery  is  accomplished  as  in  other  instances. 

B.— MECHANISM   OF  EIGHT  MENTO-ILIAC  POSITION. 

This  is  the  most  frequent  of  the  face  presentations,  and  is  usually 
named  the  first  position.  The  positions  of  the  diameters  of  the  fetal 
head,  and  their  relations  with  the  pelvic  diameters,  will  be  the  same 
as  in  the  left  mento-iliac  cases;  the  exceptions  are,  that  in  the  present 
position  the  forehead  corresponds  to  the  left  iliac  fossa,  and  the  chin 
to  the  right  iliac  fossa;  the  child's  back  is  toward  the  left  side  of  the 
mother,  and  its  abdomen  toward  her  right  side ;  its  right  side  is  in 
front,  its  left  behind,  and  the  feet  are  above  and  to  the  left.  (Fig.  56.) 
The  right  side  of  the  face  is  anterior  and  more  depressed  than  the 
other  side,  and  the  finger  comes  in  contact  with  the  right  eye  or  malar 
bone,  anu  upon  which  part  is  formed  the  primary  tumor.  The 
mechanism  in  this  case  is  precisely  similar  to  the  one  just  described, 
with  the  exception  that  rotation  takes  place  from  right  to  left,  the 
spine  of  the  right  ischium  being  the  directing  agent  and  acting  upon 
the  left  side  of  the  chin. 

TREATMENT. — Although  face  presentations  are  accidents,  or 
deviations  from  vertex  positions,  yet,  as  a  general  rule,  the  natural 
powers  will  be  found  adequate  to  safely  terminate  the  labor,  and  the 
practitioner  must  not  interfere  as  long  as  the  pains  are  regular  and 
energetic,  the  parts  cool,  the  patient  free  from  febrile  symptoms,  and 
the  head  advancing,  however  slowly.  If,  however,  the  pains  become 
feeble  and  insufficient,  or  accidents  should  occur,  then  interference  will 
be  required.  Turning  was  formerly  recommended  by  authors,  but 
from  the  difficulty,  and  the  danger  to  both  the  mother  and  child, 
attending  this  operation,  it  is  at  the  present  day  very  rarely  attempted 
and  is  not  advised  by  recent  authorities. 


422  KING'S  ECLECTIC  OBSTETRICS. 

In  relation  to  face  presentations,  Dr.  Dewees  has  recommended  the 
following  manipulation : 

"In  the  first  and  second  positions,  we  must  have  the  concurrence 
of  the  following  circumstances,  before  we  attempt  the  reduction  of 
the  head;  first,  the  uterus  must  be  sufficiently  open  to  permit  the 
hand  to  pass,  with  little  or  no  difficulty;  second,  the  head  must  not 
have  entirely  passed  the  superior  strait ;  third,  the  waters  must  have 
been  recently,  expended.  If  these  advantages  combine,  after  having 
the  woman  properly  placed,  a  hand  must  be  passed  into  the  uterus; 
and  the  choice  of  the  hand  is  a  matter  of  the  first  consequence  to  tin- 
success  of  the  operation:  the  governing  rule  is  simple,  and  easily 
remembered;  namely,  the  hand  which  is  to  the.  side  on  which  the 
vertex  and  forehead  are  placed ;  that  is,  in  the  first,  the  right  hand 
must  be  used;  because,  when  before  the  patient,  the  right  hand  otters 
to  the  left  side  of  her,  or  the  pelvis ;  if  the  second  be  the  position,  the 
left  hand  must  be  employed,  for  a  like  reason.  [These  positions  are 
reversed,  in  my  arrangement.  K.] 

"In  the  first  position  of  the  face,  we  pass  the  right  hand  into  the 
uterus  in  such  a  manner  as  shall  put  the  back  of  the  fingers  to  the 
posterior  part  of  the  pelvis,  or  before  the  left  sacro-iliac  symphysi.-, 
and  place  them  on  the  side  of  the  head,  while  the  thumb  is  pressed 
against  the  opposite  side ;  the  hea.d  is  then  to  be  firmly  grasped,  and 
raised  to  the  entrance  of  the  superior  strait.  When  the  head  is  thus 
poised,  the  extremities  of  the  fingers  are  to  be  carried  over  the  vertex, 
while  the  thumb  is  moved  to  the  center  of  the  upper  part  of  the  fore- 
head ;  the  fingers  are  then  made  to  draw  the  vertex  downward,  while 
the  thumb  tends  by  its  pressure,  to  carry  the  face  upward,  thus 
executing  a  compound  action  upon  the  head.  All  this,  it  should  be 
remembered,  must  be  executed  in  the  absence  of  pain;  if  we  find, 
when  pain  comes  on,  that  the  vertex  moves  sufficiently  downward, 
and  the  face  upward,  to  give  assurance  it  will  now  descend,  we  may 
withdraw  the  hand,  and  trust  the  rest  to  the  action  of  the  uterus. 
But  if,  on  the  contrary,  upon  the  accession  of  the  pain,  we  find  the  face 
still  has  a  tendency  downward,  we  may  be  certain  that  the  reduction  is 
incomplete;  and  we  must  again  and  again  attempt  it,  in  the  absence 
of  pain,  if  it  be  necessary :  for,  under  the  circumstances  I  have  stated, 
we  are  pretty  sure  of  success  under  a  well-directed  management. 

"  In  the  second  position,  we  employ  the  left  hand,  under  the  condi- 
tions I  have  stated  for  the  first,  and  act  in  every  respect  as  directed 
for  that  presentation." 


DIFFICULT  LABOR — FliOM   MA  [.-POSITION  OF. THE  HEAD,  ETC.    423 

It  is  extremely  doubtful  whether  this  manipulation  can  really  be 
effected;  in  the  first  place,  if  the  waters  have  been  discharged,  it  will 
be  very  difficult,  if  not  impossible  to  introduce  the  hand  as  stated,  from 
the  brim  being  occupied  by  the  head,  and  the  fetus  being  directly 
pressed  upon  by  the  uterine  walls,  besides  the  attempt  will  be  exceed- 
ingly painful.  In  the  second  place,  a  failure  will  expose  the  mother 
to  the  still  more  dangerous  necessity  of  pelvic  version,  the  forceps,  or 
even  the  perforator,  and  more  especially  should  the  presentation  be 
complicated  with  descent  of  an  arm  or  foot,  or  prolapse  of  the  cord. 

Most  generally,  the  existence  of  a  face  presentation  is  not  ascer- 
tained until  the  part  has  so  far  descended  into  the  pelvic  cavity,  as  to 
render  it  impossible,  either  to  push  it  into  the  upper  pelvis,  or  effect 
the  above  operation  of  bringing  down  the  vertex.  In  such  instances,, 
it  will  become  necessary  to  be  guided  by  the  general  principle  of 
obstetrics,  to  wait  until  symptoms  present  which  indicate  the  need  of 
artificial  aid,  and  then  make  use  of  those  means  best  calculated  to 
overcome  the  difficulty.  The  vectis  will  probably  be  found  the  most 
appropriate  instrument  in  a  majority  of  cases;  if  the  head  be  low 
down,  and  particularly  if  rotation  does  not  occur,  the  forceps  may,, 
perhaps,  be  employed  advantageously — though  the  selection  of  the 
instrument  must  depend  upon  the  peculiar  character  of  the  case,  and 
the  judgment  of  the  practitioner.  •  If  these  means  fail,  the  only  resource 
is  craniotomy.  The  perforator,  however,  will  not  be  needed  except 
in  extreme  cases;  and  should  not  be  resorted  to  until  all  hope  of  de- 
livery by  the  forceps  is  abandoned,  and  only  then  after  the  concur- 
rence of  another  physician.  The  reckless  sacrifice  of  the  child's  life 
is  too  often  the  case  under  such  circumstances.  The  delivery  can 
usually  be  accomplished  with  the  forceps,  where  operative  interfer- 
ence becomes  necessary.  In  these  cases,  much  patience,  gentleness 
and  sympathy  are  required  on  the  part  of  the  practitioner,  who  must 
encourage  his  patient  from  time  to  time,  and  endeavor  to  keep  her 
from  becoming  depressed  and  discouraged. 

I  have  not,  heretofore,  named  the  only  and  positive  rule  to  be 
observed  in  all  face  cases,  whatever  may  be  their  position,  viz.:  to  bring 
the  chin  to  the  pubic  arch,  so  that  the  original  flexion  of  the  head  may 
be  restored  as  soon  as  possible  after  the  delivery  of  the  chin ;  and 
in  by  far  the  greater  number  of  instances  in  which  this  rotation 
is  effected,  the  labor  will  terminate  without  any  formidable  re- 
sults. If  this  rotation  can  not  be  effected,  and  the  forehead 
should  present  at  the  pubic  symphysis,  the  practitioner  must  make 
use  of  means  the  most  applicable  to  the  emergency.  Professor 


424  KING'S  ECLECTIC  OBSTETRICS. 

Meigs  remarks,  that  in  all  face  presentations,  "  the  great  doctrine 
is,  to  bring  the  chin  to  the  pubic  arch,  because  the  chin,  being  the 
mental  extremity  of  the  five-inch  mento-occipital  diameter,  may  escape 
by  gliding  an  inch  downward,  behind  the  symphysis  pubis;  whereas, 
if  it  be  directed  backward  to  the  sacrum,  it  must  slide  five  inches 
down  the  sacrum  and  coccyx,  and  from  three  to  three  and  a  half 
inches  over  the  extended  perineum  before  it  can  be  born ;  but  five 
inches  and  three  inches  make  eight  inches.  The  child's  neck  is  not 
eight  inches  long.  Therefore,  before  the  chin  can  slide  down  the 
sacrum,  and  off  the  anterior  edge  of  the  extended  perineum,  a  good 
part  of  the  child's  thorax  must  be  pressed  or  jammed  into  the  excava- 
tion along  with  the  head,  the  vertical  diameter  of  which  alone  is 
more  than  three  and  a  half  inches."  This  is  a  correct  representation 
of  the  matter,  and  the  practice  alluded  to,  of  bringing  the  chin  to  the 
pubic  arch,  is  the  one  at  present  universally  pursued  by  all  scientific 
accoucheurs. 

6.— EAR  PRESENTATIONS,  or  Presentations  of  the  Side  of  the 
Head}  occur  very  rarely ;  they  are  considered  as  deviations  from  the 
vertex  presentations,  and  occasioned  by  an  undue  obliquity  of  the 
uterus,  or,  perhaps,  in  some  instances,  an  abnormal  amount  of  liquor 
amnii.  In  20,517  instances,  they  have  been  met  with  only  six  times, 
five  of  which  were  of  the  left  side  of  the  head,  and  the  remaining  one 
of  the  right.  They  are  known  by  the  presence  of  an,  ear  at  the  supe- 
rior strait.  Each  side  of  the  head  may  present  in  three  different  posi- 
tions, which  are  determined  by  the  relations  of  the  ear  to  the  maternal 
pelvis ;  they  have  been  classified  as  follows : 

PRESENTATION  OF  THE  EIGHT  SIDE. 

1st.   Position Lobulo  pubal. 

2d.  Position Right   lo!  ulo-iliac. 

3d.  Position Left  lobulo-iliac. 

PRESENTATION  OF  THE  LEFT  SIDE. 

1st.  Position Lobulo-pubal. 

"Id.  Position Right  lobulo-iliac. 

3d.  Position Left  lobulo-iliac, 

DIAGNOSIS.— As  there  is  no  part  of  the  fetal  body  likely  to  be 
•confounded  with  the  ear,  its  detection  may  be  accomplished  with  but 
little  difficulty.  The  ear  may  be  felt,  with  the  surrounding  bony 


DIFFICULT  LABOR — FROM  MAL-POSITION  OF  THE  HEAD,  ETC.    426 

head ;  we  know  the  face  to  be  situated  anterior  to  the  tragus,  and  the 
occiput  to  be  behind  the  helix,  or  circumference  of  the  ear,  so  that 
from  these  marks  we  may  readily  determine  the  position  of  the  head. 

A.— In  the  LOBULO-PUBAL  POSITION,  of  the  Right  Side  of 
the  Head,  the  lobe  of  the  ear,  as  well  as  the  base  of  the  cranium,  look 
toward  the  pubes,  the  long  diameter  of  the  external  ear  presents  in 
the  direction  of  the  antero-posterior  diameter  of  the  superior  strait, 
the  vertex  is  at  the  promontory  of  the  sacrum,  the  convexity  of  the 
helix  and  the  occiput  are  directed  toward  the  left  side  of  the  pelvis, 
and  the  face  and  tragtis  toward  the  right  side.  The  child's  back  is 
toward  the  left  side  of  the  mother,  its  front  toward  her  right  side,  its 
left  side  looks  posteriorly,  its  right  side  anteriorly,  and  its  feet  are 
above  and  to  the  right. 

Tiiis  is  a  deviation  of  a  left  occipito  position,  produced  by  an  ante- 
rior obliquity  of  the  uterus,  and  should  be  remedied  by  placing  the 
patient  upon  her  back,  with  the  pelvis  somewhat  elevated,  raising  the 
fund  us  upward  and  backward,  and  then  applying  a  bandage  firmly 
around  the  abdomen.  The  obliquity  removed,  the  vertex  passes  in 
front  of  the  sacral  promontory,  the  head  rises,  and  gradually  recovers  its 
original  left  occipito  position,  and  the  delivery  is  terminated  naturally. 

B.— In  the  RIGHT  LOBULO-ILIAC  POSITION,  of  the  Right 
Side  of  the  Head,  the  lobe  of  the  ear  looks  toward  the  right  side  of 
the  pelvis,  the  long  diameter  of  the  external  ear  presents  in  the  direc- 
tion of  the  transverse  diameter  of  the  pelvis  (or  nearly  so),  the  vertex 
is  at  the  left  iliac  fossa,  the  convexity  of  the  helix  and  the  occiput  are 
directed  toward  the  pubes,  and  the  face  and  tragus  toward  the  sacrum. 
The  child's  back  is  anteriorly,  its  front  posteriorly,  its  left  side  is 
toward  the  left  of  the  mother,  its  right  side  toward  her  right,  and  the 
feet  above,  and  toward  her  left,  and  back. 

This  is,  likewise,  a  deviation  from  a  left  occipito  position,  occasioned 
by  an  extreme  right  lateral  uterine  obliquify,  and  should  be  managed 
by  placing  the  female  on  her  left  side,  elevating  the  fundus  upward 
and  to  the  left,  and  applying  the  bandage  as  before.  The  obliquity 
removed,  the  head  engages  in  the  brim,  and  the  delivery  terminates 
naturally. 

C.— In  the  LEFT  LOBULO-ILIAC  POSITION,  of  the  Right 
Side  of  the  Head,  the  lobe  of  the  ear  is  toward  the  left  side  of  the 
pelvis,  the  long  diameter  of  the  concha  is  parallel,  or  nearly  so,  to  the 
pelvic  transverse  diameter,  the  vertex  is  at  the  right  iliac  fossa,  the 


420  KING'S  ECLECTIC  OBSTETRICS. 

convexity  of  the  helix  and  the  occiput  look  toward  the  sacrum,  and 
the  face  and  tragus  toward  the  pubes.  The  child's  back  is  toward 
the  maternal  back,  its  front  anteriorly,  its  left  side  toward  the  right 
of  the  mother,  its  right  toward  her  left,  and  the  feet  above,  and  toward 
her  right,  and  front. 

This  is  a  rare  presentation,  and  is  a  deviation  from  a  left  occipito- 
posterior  position  ;  it  is  produced  by  an  extreme  left  lateral  obliquity. 
The  treatment  is  similar  to  the  previous  instances  ;  the  female  must 
be  placed  upon  her  left  side  and  bandaged ;  the  vertex  engages  in  the 
brim,  and  the  labor  terminates  as  in  a  left  occipito-posterior  position. 

In  these  lateral  obliquities,  the  object  of  the  bandage  is  to  prevent 
the  uterus,  after  a  change  in  its  position  has  been  effected,  from  return- 
ing to  its  original  inclination. 

D._ When  the  LEFT  SIDE  OF  THE  HEAD  presents,  the 
relations  with  the  pelvis  are  the  same  as  in  the  preceding  instances 
but  the  partial  relations  are  inverted.  Thus,  in  the  LOBULO-PU- 
BAL  POSITION  of  the  Left  Side  of  the  Head,  the  lobe  of  the  ear 
is  toward  the  pubes,  the  long  diameter  of  the  concha  corresponds  with 
the  pelvic  antero-posterior  diameter,  and  the  vertex  is  at  the  sacral 
promontory ;  but  the  convexity  of  the  helix  and  the  occiput  are 
directed  toward  the  right  side  of  the  pelvis,  and  the  face  and  tragus 
toward  the  left.  The  child's  back  is  toward  the  right  side  of  the 
mother,  its  front  toward  her  left  side,  its  left  side  looks  anteriorly,  its 
right  posteriorly,  and  its  feet  are  above  and  to  the  left. 

E.— In  the  RIGHT  LOBULO-ILIAC  position  of  the  left  side, 
the  lobe  of  the  ear  will  be  directed  toward  the  right  side  of  the  pelvis, 
the  vertex  toward  the  left,  the  occiput  and  convexity  of  the  helix 
toward  the  sacrum,  and  the  face  and  tragus  toward  the  pubes.  The 
fetal  back  will  be  directed  backward,  its  anterior  plane  in  front,  its  left 
side  to  the  right  of  the  mother,  its  right  to  her  left,  and  its  feet  above, 
toward  her  left  and  front. 

F.— In  the  LEFT  LOBULO-ILIAC  position  of  the  left  side,  the 
lobe  of  the  ear  is  to  the  left  side  of  the  pelvis,  the  vertex  to  the  right, 
the  convexity  of  the  helix  toward  the  pubes,  and  the  tragus  toward 
the  sacrum.  The  fetal  back  is  directed  to  the  front  of  the  mother,  its 
front  to  her  back,  its  left  side  to  her  left,  its  right  side  to  her  right, 
and  its  feet  above,  toward  her  right,  and  back.  All  these  mal-positions 
are  to  be  rectified  upon  the  general  principles  described  above;  if  these 
fail,  efforts  may  be  made  to  bring  down  the  vertex,  when  the  head  is 
at  the  brim,  by  a  manipulation  (somewhat  similar  to  that  recommended 


DIFFICULT  LABOR — FROM  M  A  L- POSITION  OF  THE  HEAD,  ETC.     427 

by  Dr.  Dewees  for  restoring  face  presentation  to  vortex,  and  which  is 
extracted  from  his  Obstetrics  and  noticed  in  the  present  chapter),  in 
which  the  head  will  have  to  be  slightly  elevated,  and  then  have  lateral 
or  anterior  pressure  or  pushing  made  upon  the  vertex  in  a  direction 
toward  the  chin,  followed  by  a  drawing  down  of  the  vertex.  It  may 
be  best  performed,  after  reduction  of  the  uterine  obliquity  and  the 
application  of  the  bandage,  by  placing  the  patient  on  her  hands  and 
knees,  with  the  hips  elevated  and  the  shoulders  depressed,  which 
position  will,  in  a  measure,  remove  the  weight  of  the  child's  head 
from  the  brim,  and  thus  facilitate  the  operation.  This  operation,  how- 
ever, will  seldom  be  needed,  and  may  frequently  fail.  In  cases 
requiring  further  aid,  it  will  be  prudent  to  wait,  in  order  to  ascertain 
the  adequacy  of  the  natural  efforts ;  and  should  these  fail,  or  the  usual 
symptoms  demanding  interference  present  themselves,  the  delivery 
must  be  terminated  by  the  vectis,  the  forceps,  or  the  perforator,  as  the 
exigencies  of  the  case  may  require.  Turning  has  been  recommended, 
previous  to  the  rupture  of  the  membranes,  when  the  os  uteri  is  con- 
siderably dilated,  soft,  and  dilatable,  and  may  possibly  be  advantageous 
in  some  cases;  but  after  the  membranes  have  given  way,  it  must  not 
be  attempted. 

7.— Labor  may  be  rendered  difficult,  by  a  COMPOUND  PRE- 
SENTATION, in  which  one  of  the  Extremities  Presents  with  the  Head, 
as  a  hand,  arm,  or  foot.  While  the  fetus  is  within  the  uterus,  its 
position  is  generally  with  the  arms  across  the  chest,  and  sometimes 
with  one  or  both  hands  against  each  ear  on  the  sides  of  the  head;  in 
these  latter  instances,  when  the  membranes  rupture  and  the  liquor 
amnii  is  discharged,  one  or  both  hands,  or  even  the  whole  arm,  may 
descend  with  the  head,  and  this  is  more  apt  to*  occur  when  the  mem- 
branes have  ruptured  prematurely.  These  compound  presentations 
are  frequently  occasioned  by  a  large  pelvis,  and  when  such  is  the  case, 
the  delivery  may  be  safely  accomplished  without  assistance.  But  when 
the  pelvis  is  small,  the  presence  of  the  limb  or  hand  increases  the 
diameter  of  the  head,  and  prevents  its  descent  into  the  cavity;  and  if 
the  uterine  contractions  are  energetic,  an  arrest  or  impaction  of  the 
head  may  take  place  at  the  superior  or  inferior  strait,  and,  perhaps, 
terminate  fatally.  When  the  foot,  hand,  or  arm  presents  with  the 
head,  it  must  be  pushed  back  with  two  or  three  fingers,  during  the 
absence  of  a  pain,  and  held  there  until  one  or  more  subsequent  pains 
causes  the  head  to  descend  so  low  as  to  prevent  any  further  falling  of 


428  KING'S  ECLECTIC  OBSTETRICS. 

the  extremity,  after  which  the  labor  must  be  left  to  the  natural  powers. 
In  performing  this  operation,  the  accoucheur  must  be  exceedingly 
careful  not  to  draw  the  arm  or  hand  down,  nor  to  displace  the  head,  as 
he  might  thereby  convert  the  case  into  a  shoulder  presentation.  In 
order  to  effect  a  successful  manipulation  of  this  kind,  the  whole  hand 
will  require  to  be  introduced  into  the  vagina,  and  partly  through  the 
os  uteri.  The  operation  should  not  be  attempted  until  the  ps  uteri  is 
sufficiently  dilated,  and  the  expulsive  pains  have  commenced ;  for  if 
it  be  attempted  in  the  first  stage  of  labor,  there  will  be  more  danger 
of  displacing  the  head,  and  of  producing  an  unnecessary  degree  of 
irritation  of  the  cervix  uteri,  and  the  practitioner  should  be  governed 
by  this  rule,  even  should  the  membranes  have  become  prematurely 
ruptured.  The  upper  extremities  will  generally  be  more  easily 
returned,  on  account  of  their  less  volume,  than  the  lower. 

If  the  limb  can  not  be  returned,  the  practitioner  must  wait,  as  in 
other  instances,  until  satisfied  that  the  natural  ettprts  are  inadequate  to 
terminate  the  labor,  and  unfavorable  symptoms  begin  to  manifest 
themselves,  when  it  will  become  necessary  to  turn,  or  employ  the 
forceps,  or  perform  craniotomy,  according  to  the  peculiar  circumstances 
of  the  case.  It  is  impossible  to  lay  down  any  special  management  of 
these  cases:  each  one  will  have  its  own  peculiarities,  which,  together 
with  the  tact  and  judgment  of  the  attending  accoucheur  and  his 
medical  advisers,  must  determine  the  course  to  be  pursued. 

Sometimes  both  the  hands  and  feet  will  present  together,  when  it 
may  become  necessary  to  bring  down  the  feet  (and  more  especially 
when  the  feet  present  with  the  breech),  and  thus  convert  it  into  a 
.  footling  case.  In  doing  this,  the  practitioner  can  not  be  too  careful  in 
his  examination,  lest  he  occasion  a  descent  of  the  arm  or  hand,  or 
bring  down  a  hand  instead  of  a  foot.  Should  there  be  a  prolapse  of 
the  cord,  in  connection  with  these  limb  presentations,  the  case  becomes 
still  more  serious,  as  far  as  the  child  is  concerned ;  and  the  manage- 
ment should  be  in  accordance  with  the  rules  hereafter  given  for  this 
•complication — hastening  the  delivery  as  soon  as  the  pulsations  are 
found  to  diminish. 


PRETERNATURAL    LABOR PELVIC    PRESENTATIONS. 


CHAPTER    XXXIII. 

ON    PRETERNATURAL    LABOR PELVIC    PRESENTATIONS. 

PRETERNATURAL  LABOR,  is  where  the  head  does  not  present, 
as,  in  shoulder  or  breech  presentations;  prolapsus  of  the  umbilical 
^cord,  plurality  of  children,  and  monsters,  are  likewise  included  in  this 
class.  Females  frequently  have  preternatural  presentations  in  several 
successive  labors,  and  it  is  impossible  to  assign  any  satisfactory  cause 
for  them.  They  can  not  be  the  results  of  violent  shocks  experienced 
during  gestation,  for  they  more  frequently  occur  in  cases  where  the 
period  of  pregnancy  has  passed  free  from  any  accidents.  Dr.  Denman, 
in  1795,  remarked:  "It  seems  doubtful,  therefore,  whether  we  ought 
not  to  exclude  accidents  as  the  common  causes  of  these  presentations, 
and  search  for  the  real  cause  from  some  more  intricate  circumstance ; 
such  as,  the  manner  after  which  the  ovum  may  pass  out  of  the  ovarium 
into  the  uterus;  some  peculiarity  in  the  form  of  the  cavity  of  the 
uterus  or  abdomen ;  in  the  quantity  of  the  waters  of  the  ovum  at 
some  certain  time  of  pregnancy ;  or,  perhaps,  in  the  insertion  of  the 
funis  into  the  abdomen  of  the  child,  which  is  not  in  all  cases  confined 
to  one  precise  part,  but  admits  of  considerable  variety."  At  the 
present  day  we  are  no  further  enlightened  on  this  point  than  were  the 
profession  in  his  time.  Some  instances  may,  probably,  be  owing  to 
uterine  obliquity,  or  to  peculiarity  of  the  formation  of  the  pelvis; 
thus,  in  three  successive  labors,  I  have  delivered  the  same  female  by 
turning,  each  instance  being  a  shoulder  presentation  in  the  second  left 
cephalo-iliac  position.  This  person,  when  young,  had  been  employed 
to  take  care  of  children,  and  was  in  the  habit  of  carrying  them  the 
greater  part  of  the  time  on  one  hip ;  the  crest  of  the  left  ilium  was 
from  an  inch  to  an  inch  and  a  half  higher  than  that  of  the  right,  when 
she  stood  erect.  Whether  this  irregularity  was  owing  to  the  manner 
in  which  she  held  the  children  during  her  youth,  or  whether  it  was 
the  occasion  of  the  shoulder  presentations,  I  am  not  prepared  to  state: 
it  is  very  difficult,  in  such  obscure  matters,  to  obtain,  from  one  or  two 
incidents  connected  with  them,  more  than  suggestions. 


430  KING'S  ECLECTIC  OBSTETRICS. 

During  gestation  it  is  a  very  difficult,  if  not  an  impossible  matter, 
for  females  to  determine  with  certainty  a  preternatural  position:  they 
may  suspect  that  such  is  the  case,  and  may  almost  be  positive  of  it, 
from  certain  circumstances  not  usual  with  them  during  this  period ; 
yet  although  their  fears  are  occasionally  confirmed  when  the  labor 
•comes  on,  they  more  frequently  find  themselves  mistaken.  Nor  is  it  a 
more  easy  task  for  the  accoucheur  to  ascertain,  during  pregnancy,  a 
preternatural  presentation,  although  some  have  professed  an  ability  to 
decide  by  the  sensation  imparted  to  the  hand,  upon  an  abdominal 
exploration  over  the  uterus  at  an  advanced  period;  also,  by  the  situa- 
tion at  which  the  pulsations  of  the  fetal  heart  are  heard.  But  I  place 
no  confidence  in  these  methods,  either  singly  or  combined.  It  is  not> 
until  the  labor  has  actually  commenced,  that  we  can  learn  with  posi- 
tiveness  the  presentation  of  some  other  part  than  the  head.  When 
the  membranes  do  not  present  the  globular  form  usual  in  head  presen- 
tations, but  may  be  felt  protruding  into  the  vagina,  having  a  peculiar, 
elongated,  or  conical-pointed  shape,  we  may  suspect  a  preternatural 
presentation,  though  this  has  been  occasionally  met  with  in  vertex 
positions.  "  Sometimes,  before  the  os  uteri  is  much  dilated,  the  mem- 
branes, filled  with  liquor  amnii,  pass  into  the  upper  part  of  the  vagina, 
and  form  a  considerable  sac  with  a  narrow  neck." — (Lee.}  A  spontane- 
ous and  premature  rupture  of  the  membranes,  is  generally  a  diagnostic 
sign  of  preternatural  presentation,  in  which  case  an  internal  exam- 
ination should  be  made  as  soon  as  possible,  in  order  to  determine  its 
character.  If,  previous  to  the  rupture  of  the  membranes,  when  the  os 
uteri  is  somewhat  dilated,  we  can  not  feel  the  presenting  part,  or,  if 
felt,  it  is  more  movable,  less  smooth,  globular,  and  resisting,  than  the 
head,  a  preternatural  presentation  may  be  suspected:  such  instances 
must  be  closely  watched,  and  great  care  be  had  not  to  rupture  the 
membranes,  as  an  early  discharge  of  the  liquor  amnii  will  render  the 
operation  of  turning  very  difficult,  or  entirely  impossible.  Sometimes 
a  foot,  or  a  hand,  or  the  umbilical  cord,  may  be  felt  and  clearly  recog- 
nized through  the  membranes,  but  usually  the  presenting  part  can  not 
be  ascertained  until  these  have  ruptured. 

In  all  labors,  it  is  of  great  importance  that  the  practitioner  should 
ascertain,  as  early  as  possible,  the  nature  of  the  presentation,  in  order 
that,  where  assistance  is  required,  it  may  not  be  delayed  until  the 
golden  opportunity  for  saving  mother  and  child  is  lost.  And,  when- 
ever he  is  positively  satisfied  that  some  other  part  than  the  head 
presents,  he  should  inform  the  nurse,  or  friends  of  the  patient,  of 
the  fact. 


PRETERNATURAL    LABOR PELVIC    PRESENTATIONS.  431 

Presentations  of  the  head  are  by  far  more  common  than  those  of 
:any  other  part  of  the  child,  and  have,  therefore  been  arranged  under 
the  head  of  Natural  Labors;  other  presentations  being  less  frequently 
met  with,  will  be  considered  under  the  present  head  of  Preternatural 
Labors.  A  preternatural  labor  may  terminate  by  the  natural  powers, 
but  the  labors  are,  as  a  general  rule,  slow  and  tedious,  more  painful 
to  the  mother,  and  more  hazardous  to  the  child  than  iu  head  presenta- 
tions; accidents  are,  likewise,  more  apt  to  take  place,  requiring  artifi- 
cial assistance. 

PRESENTATIONS  OF  THE  PELVIC  EXTREMITIES,  as 
of  the  breech,  knees,  or  feet,  belong  to  preternatural  labors.  In  the 
majority  of  these  cases  the  delivery  may  be  safely  effected  by  the  natural 
powers,  in  consequence  of  which  some  eminent  authors  have  included 
them  among  natural  labors ;  but  I  consider  the  present  arrangement 
as  being  more  in  accordance  with  the  nature  of  the  cases,  and  better 
adapted  to  facilitate  an  acquaintance  with  them.  From  the  statistics 
heretofore  cited,  which  are  the  recorded  statements  of  British,  French 
and  German  accoucheurs,  it  will  be  observed  that  the  danger  to  the 
child  is  much  greater  in  pelvic  presentations  than  in  those  of  the 
head,  and  that  the  cases  in  which  the  inferior  extremities  present  are 
more  hazardous  than  in  true  breech  deliveries. 

The  principal  danger  in  these  breech  labors  is  to  the  child ;  the 
soft  passages  are  not  so  thoroughly  dilated  by  the  body  as  by  the  head, 
because  the  breech,  even  with  the  legs  turned  up,  does  not  present  so 
great  a  bulk  in  circumference  or  diameters  as  the  head,  and  conse- 
quently, when  the  head  is  in  the  pelvic  cavity,  it  can  not  descend  until  the 
parts  become  still  further  distended  and  better  adapted  for  its  advance. 
This  renders  the  delivery  of  the  head  slow  and  tedious,  during  which 
the  cord  may  be  exposed  to  a  pressure  resulting  in  fetal  asphyxia; 
or  the  same  result  may  ensue  from  detachment  of  the  placenta,  before 
the  head  has  passed  the  outlet;  or  by  pressure  upon  the  placenta  when 
situated  between  the  fetal  head  and  the  uterine  walls ;  in  either  of 
which  instances  the  utero-placental  circulation  is  suspended.  The 
first  (compression  of  the  cord)  is  a  more  common  cause  of  the  child's 
death  in  footling  presentations;  the  latter,  in  those  of  the  breech. 
When  the  thighs  are  not  flexed  upon  the  abdomen,  the  child  being 
delivered  by  the  feet  or  knees,  the  head  will  advance  more  slowly,  in 
consequence  of  the  greater  resistance  offered  to  it,  than  where  the 
limbs  are  turned  up,  and  the  greater  delay  and  longer-continued  pres- 
sure upon  the  cord  renders  this  species  of  pelvic  deliveries  more  fatal 
to  the  child. 


432  KING'S  ECI-KITR-  OBSTETRICS. 

The  danger  to  the  mother  in  these  cases  is  owing  entirely  to  a  delay 
in  the  second  stage  of  labor  beyond  a  certain  period,  to  injuries  of  the 
soft  parts  from  compression,  or  improper  efforts  to  facilitate  the  childV 
expulsion,  and  to  narrowness  or  deformity  of  the  pelvis. 

DIAGNOSIS. — Previous  to  labor  a  pelvic  presentation  may  some- 
times be  ascertained,  especially  among  women  whose  abdominal  walls 
are  thin,  soft,  and  flaccid,  by  feeling  the  fetal  head  in  the  upper  part 
of  the  uterus,  inclined  either  toward  the  right  or  left  side;  if  auscul- 
tation be  resorted  to,  the  pulsation  of  the  fetal  heart  may  be  heard  in 
the  upper  portion  of  the  abdomen,  either  above  or  on  a  level  with  the 
umbilicus;  if  a  vaginal  exploration  be  made  it  will  be  found  difficult 
to  reach  or  distinguish  the  presenting  part,  though  sometimes,  instead 
of  the  hard,  globular  tumor  felt  in  head  presentations,  a  small  tumor, 
the  foot,  may  be  felt,  and  ballotted.  . 

But  the  most  certain  method  of  diagnosis  is  during  labor,  in  the 
absence  of  pain,  when  the  presenting  part  can  be  felt.  The  breech  may 
be  known  from  the  head  by  its  soft  and  fleshy  feel,  and  by  the  absence 
of  sutures  and  fontanelles;  it  is  not  so  round  or  so  hard  as  the  head. 
Upon  some  part  of  the  anterior  surface  will  be  felt  the  hard,  resisting 
trochanter ;  passing  the  finger  carefully  around,  the  tuberosities  of  the 
ischia  may  be  detected,  also  the  fissure  between  the  nates;  at  the  bottom 
of  this  fissure  are  found  the  most  important  signs,  as  the  sacrum,  coccyx, 
anus,  and  external  genital  organs;  and  the  anus  may  be  detected 
from  the  mouth,  by  the  difficulty,  if  not  impossibility,  of  introducing 
the  finger  into  it.  The  presence  of  the  somewhat  sharp-pointed, 
movable  coccyx  not  only  assists  us  in  determining  the  character  of  the 
presentation,  but  also  that  of  the  position,  because  its  point  or  apex  i.s 
always  directed  toward  the  side  of  the  maternal  pelvis  corresponding 
with  the  child's  abdomen.  The  presence  of  the  meconium,  which  has 
been  noticed  by  some  writers  as  a  diagnostic  sign,  is  really  of  little 
value,  as  it  is  frequently  met  with  in  head  presentations,  and  also 
occurs  as  a  sign  of  the  child's  death. 

Having  become  positively  certain  that  the  breech  presents,  it  should 
be  named  to  the  husband,  nurse,  or  some  relative,  but  great  care  must 
be  taken  to  conceal  it  from  the  patient,  lest  it  impart  a  shock  to  her 
mind  which  may  suspend  or  retard  the  labor  for  several  hours.  The 
communication  should  be  made  to  the  husband  in  a  separate  room, 
and  all  the  dangers  to  which  the  child  is  exposed,  fully  made  known, 
so  that  in  case  it  be  still-born,  the  skill  or  ability  of  the  medical 
attendant  may  not  be  called  into  question.  Should  the  sex  of  the 


PRETERNATURAL    LABOR — PELVIC    PRESENTATIONS. 


433 


child  have  been  ascertained  during  the  examination,  it  must  not  be 
made  known  to  any  one,  lest  it  reach  the  patient's  ears,  and  effect 
an  unfavorable  influence  over  the  progress  of  the  labor,  by  the  dis- 
appointment it  might  occasion  should  it  be  different  from  the  one 
desired. 

By  reference  1o  a  preceding  page  it  will  be  s'een  that  four  positions 
are  given,  in  any  one  of  which  the  breech  may  present;  and  which 
positions  are  ascertained  by  the  coccyx,  ischiatic  tuberosities,  genitals, 
etc.,  and  named  according  to  the  situation  of  the  back  or  sacrum  of 
the  child. 

1.— MECHANISM  OF  FIRST   LEFT   SACEO-ILIAC  POSITION. 

In  this  position  the  sacrum  of  the  fetus  faces  the  maternal  left  ilium 
anteriorly,  while  the  hips  or  bi-trochanteric  diameter  are  parallel  with 
the  right  oblique  diameter  of  the  superior  strait  [or,  for  a  time  with 
its  antero-posterior  or  transverse  diameter]  ;  the  abdomen,  and  pos- 
terior part  of  the  fetal  thighs  flexed  upward,  are  toward  the  right  ilium 
posteriorly,  its  left  side  is  in  front,  and  its  right  side  to  the  back  of 
the  mother;  the  head  is  slightly  flexed  on  the  chest,  and  inclined  to 
the  right  and  posteriorly.  But  in  all  the  positions  named,  as  soon  as 
the  bag  of  waters  rupture  and  all  the  liquor  amnii  escapes,  the  uterus 
comes  directly  in  contact  with  the  fetus,  perfecting  the  flexion  of  the 
head,  and  at  the  same  time  maintaining  its  limbs  in  close  contact  with 
its  body. 

As  soon  as  the  membranes  rupture, 
a  large  amount  of  the  liquor  amnii 
escapes,  and  the  presenting  part,  which 
was  previously  high  up,  engages  in  the 
brim,  and  its  position  can  now  readily 
be  ascertained.  The  hips  usually  en- 
gage in  the  direction  of  the  right 
oblique  pelvic  diameter,  occasionally 
of  the  transverse.  (Fig.  59.)  As  the 
uterine  contractions  continue,  the  nates 
generally  descend,  with  the  hips  in  the 
right  oblique  diameter,  into  the  pelvic 
cavity  until  they  arrive  at  the  inferior 
strait,  the  left  or  anterior  nates  being 
the  lowest.  [This  oblique  diameter  is 
soon  taken  by  the  hips,  should  they  be  at  first  situated  transversely.] 
At  this  point  a  slight  or  partial  rotation  sometimes,  but  not  always, 
28 


FIG.  59. 


434 


KING'S    ECLECTIC    OBSTETRICS. 


takes  place,  and  the  child's  left  hip  is  carried  slightly  to  the  left,  and 
FIG.  GO.  somewhat  toward  the  pubis,  while  its 

right  similarly  rotates  to  the  right 
toward  the  hollow  of  the  sacrum. 
(Fig.  60.)  The  left  hip  appears  first 
at  the  vulva,  under  the  pubic  arch,  the 
bi-trochanteric  diameter  being  nearly 
if  not  quite  in  the  direction  of  the 
right  oblique  diameter;  this  hip  main- 
tains its  position  there,  while  the  right 
hip  is  made  to  gradually  traverse  the 
hollow  of  the  sacrum,  and  inner  per- 
ineal  surface,  describing  an  arc  of  a 
circle  around  the  left  hip  as  a  center. 
In  some  cases  the  left  hip,  during  this 
motion  of  the  right,  ascends  behind 
the  pubic  symphysis. 

"While  the  right  hip  is  passing  over  the  posterior  wall  of  the  pelvis, 
the  body  of  the  child  becomes  curved  laterally  on  its  anterior  side,  so 
FlG  61  as  to  accommodate  itself  to  the  curvature  of 

the  pelvic  cavity.  (Fig.  61.)  This  lateral 
curvature  continues  until  the  body  is  ex- 
pelled; though  as  the  parts  are  disengaged 
they  recover  their  original  position. 

As  the  right  hip  advances  toward  the  pos- 
terior commissure,  the  bis-iliac  diameter  of 
the  fetus  corresponds  with  the  pelvic  antero- 
posterior  diameter,  and  the  process  of  resti- 
tution takes  place  after  the  delivery  of  the 
pelvis,  placing  it  in  its  original  diagonal 
position;  though,  in  most  cases,  this  oblique 

position  is  retained  throughout  the  delivery.  The  hips  having 
been  delivered,  the  fetal  breast  engages  in  the  excavation,  and  as 
the  body  descends,  the  inferior  extremities  fall  out.  The  shoulders 
are  commonly  in  the  same  oblique  pelvic  diameter  as  the  hips,  when 
they  arrive  at  the  inferior  strait,  and  are  born  in  a  similar  manner, 
the  right  or  posterior  shoulder  being  generally  delivered  first.  It 
has  been  advanced,  heretofore,  by  many  writers,  that  when  the  hips 
or  shoulders  reached  the  floor  of  the  pelvis,  that  rotation,  somewhat 
like  that  of  the  head,  occurred,  placing  one  hip  or  shoulder  under 
the  pubic  arch  and  the  other  in  the  hollow  of  the  sacrum.  But  that 


PRETERNATURAL  LABOR — PELVIC  PRESENTATIONS.      435 

careful  observer,  M.  Xseg^le  denies  this  in  something  like  the  follow- 
ing language:  "In  its  (the  breech)  farther  advance  into  the  pelvis,  it 
is  always  found  in  an  oblique  direction,  the  hip  directed  forwards 
standing  lowest.  In  this  oblique  position,  with  reference  to  its  trans- 
verse and  perpendicular  diameters,  it  is  forced  through  the  inlet,  the 
cavity,  and  the  outlet  of  the  pelvis;  and  in  general  none  of  these 
rotations  occur,  erroneously  described  in  many  manuals  and  com- 
pendia as  appertaining  to  this  species  of  labors." 

The  arms  are  usually  applied  closely  to  the  thorax,  and  are  thus 
delivered;  but  it  sometimes  happens,  that  one  or  both  of  them  get  up 
along  the  sides  of  the  head,  rendering  the  delivery  of  the  head  very 
difficult,  and  requiring  artificial  interference.  This  may  be  occasioned 
by  the  smallness  of  the  pelvis,  or  the  unusual  size  of  the  child;  but 
it  more  commonly  arises  from  an  imprudent  traction  made  by  the 
accoucheur  on  the  pelvic  extremity,  in  order  to  facilitate  the  delivery, 
and  which  improper  interference  may  still  further  increase  the  diffi- 
culty of  the  labor,  by  effecting  an  extension  of  the  head.  In  ordinary 
instances,  where  one  arm  has  been  thrown  up  by  the  side  of  the  head, 
it  will  most  commonly  be  the  one  behind  the  pubic  symphysis. 

While  the  shoulders  are  being  disengaged,  the  head,  usually  well 
flexed  upon  the  thorax,  has  entered  the  superior  strait  in  the  direction 
of  its  left  oblique  diameter,  the  forehead  being  toward  the  right  sacro- 
iliac  symphysis,  and  the  occiput  toward  the  left  acetabulum,  which 
flexion  and  diagonal  position  it  retains  until  it  has  reached  the  inferior 
strait.  At  this  strait,  the  relation  of  the  pelvic  diameters  with  those 
of  the  fetal  head  will  vary  according  to  the  degree  of  flexion.  If  the 
flexion  be  moderate,  the  occipito-frontal  diameter  will  be  parallel  to 
the  left  oblique  of  the  strait,  and  the  bi-parietal  to  the  right  oblique, 
while  the  trachelo-bregmatic  diameter  will  very  nearly  correspond 
with  the  axis  of  the  inferior  strait.  But  if  there  be  a  greater  degree 
of  flexion,  the  sub-occipito-bregmatic  will  correspond  with  the  pelvic 
left  oblique  diameter,  and  the  axis  of  the  lower  strait  will  very  nearly 
pass  in  the  direction  of  the  occipito-mental  diameter. 

Upon  arriving  at  the  inferior  strait,  the  head  undergoes  the  move- 
ment of  rotation,  by  which  the  face  is  carried  into  the  hollow  of  the 
sacrum,  the  occiput  behind  the  symphysis  pubis,  and  the  n«ck  under 
it;  the  sub-occipito-bregmatic  diameter  is  placed  nearly  in  correspond- 
ence with  the  pelvic  antero-posterior.  At  this  period,  the  head  is 
nearly,  or  altogether  in  the  vagina,  and  consequently  the  contractions 
of  the  uterus  exert  but  little  or  no  expulsive  influence  upon  it;  the 
further  progress  of  the  head  is,  therefore,  to  be  effected  by  the  con- 


436  KING'S  ECLECTIC  OBSTETRICS. 

tractions  of  the  abdominal  muscles.  As  the  neck  is  situated  firmly 
against  the  pubic  arch,  preventing  the  descent  of  the  occiput,  the 
contractions  will  occasion  the  head  to  become  more  and  more  flexed 
upon  the  chest,  and  while  this  motion  is  taking  place,  the  chin,  face, 
forehead,  and  posterior  fontanelle,  traverse  the  internal  face  of  the 
sacrum  and  perineum,  and  successively  appear  in  front  of  the  posterior 
commissure  of  the  vulva,  while  the  occiput  is  the  last  delivered. 

2.— MECHANISM  OF  FIRST  RIGHT  SACRO-ILIAC  POSITION. 

In  this  position  the  sacrum  of  the  fetus  faces  the  maternal  right 
ilium  anteriorly,  while  the  bi-trochanteric  diameter  is  parallel  with  the 
left  oblique  diameter  of  the  superior  strait  [or,  for  a  time,  with  it* 
antero-posterior  or  transverse  diameter] ;  the  abdomen,  and  posterior 
part  of  the  fetal  thighs  flexed  upward,  are  toward  the  left  ilium 
posteriorly,  its  right  side  is  in  front,  and  its  left  side  to  the  mother's 
back ;  the  head  is  flexed  and  inclined  to  the  left  and  posteriorly. 

The  mechanism  in  this  position  is  precisely  similar  to  the  one  just 
described,  with  the  exception  of  an  inversion  of  the  relations  of  the 
parts.  The  right  hip  is  the  one  placed  at  or  near  the  pubic  arch,  while 
the  left  traverses  the  posterior  wall  of  the  pelvis.  The  right  shoulder 
assumes  the  same  oblique  diameter  as  the  hips  had  previously,  and  the 
head  engages  in  the  cavity  with  the  occiput  toward  the  right  acetabu- 
lum,  and  the  forehead  toward  the  left  sacro-iliac  symphysis. 

3.— MECHANISM  OF  SECOND  LEFT  SACRO-ILIAC  POSITION. 

In  this  position  the  sacrum  of  the  fetus  faces  the  maternal  left  ilium 
posteriorly,  while  the  bi-trochanteric  diameter  is  in  the  direction  of 
the  left  oblique  diameter  of  the  superior  strait;  the  abdomen  and 
posterior  part  of  the  thighs  flexed  upwardly,  are  toward  the  right 
ilium  anteriorly,  its  left  side  is  in  front,  and  its  right  side  to  the  mother's 
back;  the  head  is  flexed  and  inclined  to  the  right  and  anteriorly. 
The  left  hip  presents,  and  is  the  lowest  during  the  whole  of  the 
expulsion,  and  the  whole  of  the  body  is  expelled,  as  in  the  previous 
instances,  with  the  exception  of  the  abdomen  looking  forward  to  the 
right.  The  left  hip  is  the  one  placed  at  or  near  the  pubic  arch,  while 
the  right  traverses  the  posterior  wall  of  the  pelvis.  The  left  shoulder 
assumes  the  same  oblique  diameter  as  the  hips  had  previously,  and  the 
head  engages  in  the  cavity  with  the  occiput  toward  the  left  sacro-iliac 
symphysis,  and  the  forehead  toward  the  right  acetabulum.  As  with 
an  occipito-posterior  position,  when  the  head  is  in  the  pelvic  cavity 
near  the  floor  of  the  pelvis,  extensive  rotation  occurs  from  left  to  right, 


PEETEENATURAL  LABOR PELVIC  PRESENTATIONS.      437 

which  places  the  occiput  under  the  pubic  arch,  and  the  face  in  the 
hollow  of  the  sacrum.  The  whole  body  of  the  child  may  be  observed 
to  partake  in  this  rotation,  which  brings  the  back  of  the  child  to  the 
front,  and  its  abdomen  to  the  back.  The  head  is  then  born  as  in  the 
first  sacro-iliac  positions.  It  may  be  observed  here,  that  in  these 
second  sacro-iliac  positions,  it  is  better,  in  order  to  avoid  difficulty 
when  the  head  reaches  the  floor  of  the  pelvis,  to  aid  in  effecting  the 
extensive  rotation,  as  hereafter  explained  in  the  treatment  of  breech 
cases,  provided  it  does  not  take  place  naturally. 

4.— MECHANISM  OF  SECOND  EIGHT  SACRO-ILIAC  POSITION. 

In  this  position  the  sacrum  of  the  fetus  faces  the  maternal  right  ilium 
posteriorly,  while  the  bi-trochanteric  diameter  is  in  the  direction  of  the 
right  oblique  diameter  of  the  pelvic  brim;  the  abdomen,  and  posterior 
part  of  the  thighs  flexed  upwardly,  are  toward  the  left  ilium  anteriorly, 
its  right  side  is  in  front,  and  its  left  side  to  the  mother's  back ;  the 
head  is  flexed  and  inclined  to  the  left  and  anteriorly.  The  right  hip 
presents,  and  is  the  most  dependent  part.  The  mechanism  of-  this 
position  is  the  converse  of  the  preceding,  the  occiput  engaging  toward 
the  .  right  sacro-iliac  symphysis,  and  the  forehead  toward  the  left 
acetabulum. 

TREATMENT  OF    BREECH  PRESENTATIONS. 

In  all  presentations  of  the  pelvic  extremity,  the  cases  should  be  left 
to  the  natural  powers,  unless  accidents  occur  imperatively  calling  for 
assistance,  and  this  point  can  not  be  too  strongly  urged  upon  the 
student.  Great  care  must  be  taken  to  preserve  the  first  stage  of  the 
labor  as  thorough  as  possible,  that  the  os  uteri  may  become  well 
dilated,  and  not  only  should  the  accoucheur  be  extremely  careful  not 
to  rupture  the  bag  of  waters,  but  he  should  also  prevent  any  efforts 
on  the  part  of  the  woman  that  may  tend  to  this  end ;  she  should  be 
kept  quiet  and  urged  to  move  about  as  little  as  possible.  The  mere 
fact  of  a  child  being  born  "  doubled  up,"  as  in  a  breech  presentation, 
does  not  necessarily  presuppose  interference,  especially  when  we  call 
to  mind  the  diameters  of  the  parts.  The  largest  diameters  of  the  fetal 
breech,  as  the  bi-trochanteric  and  bis-iliac,  are  smaller  than  the 
bi-parietal  diameter  of  the  head,  or  the  bis-acromial  diameter.  When 
a  presentation  of  this  kind  is  met  with,  no  attempts  should  be  made  to 
bring  down  the  feet  and  inferior  extremities,  unless  there  be  proper 
cause  for  so  doing;  to  do  otherwise  is  bad,  meddlesome  practice. 
When  the  breech  descends  with  the  limbs  flexed  upon  the  abdomen, 


438  KING'S  ECLECTIC  OBSTETRICS. 

the  labor  proceeds  slowly,  sometimes  lasting  for  hours,  in  consequence 
of  the  yielding  character  of  the  presenting  parts,  which,  not  being  firm 
and  resisting,  like  the  head,  give  way,  to  a  certain  extent,  during  each 
pain,  and  thus  require  a  longer  time  to  render  the  soft  parts  of  the 
mother  sufficiently  yielding.  But  this  protractedness  in  the  delivery 
of  the  fetal  pelvis,  is  rather  to  the  child's  advantage;  for  the  maternal 
parts  become  so  thoroughly  dilated  and  yielding  thereby,  that  the  head 
passes  without  any  difficulty,  a  few  efforts  of  the  patient  being  suffi- 
cient, in  ordinary  instances,  to  expel  it  shortly  after  the  delivery  of 
the  shoulders.  But,  if  the  feet  be  imprudently  brought  down  by  an 
unskillful  accoucheur,  the  smaller  bulk  offered  to  the  soft  tissues  of 
the  maternal  generative  parts,  wrill  not  so  completely  dilate  and  adapt 
them  to  the  easy  passage  of  the  head,  which  in  consequence  may. 
be  so  long  delayed  in  its  expulsion  as  to  occasion  the  death  of  the 
child. 

Neither  is  it  proper  to  employ  any  extracting  force,  for  the  purpose 
of  facilitating  delivery,  as  the  child  may  be  destroyed  by  a  severe  and 
injurious  extension  of  the  neck;  it  being  borne  in  mind  that  the  neck 
of  the  child  before  birth  is  capable  of  sustaining  no  more  extractive 
force  than  afterward,  and  any  great  amount  of  traction  must  injure 
the  spinal  cord;  beside,  the  arms  not  being  maintained  in  their 
position  by  the  contractions  of  the  uterus,  become  arrested,  and  do 
not  simultaneously  participate  in  the  descent  accomplished  artifi- 
cially by  traction;  hence,  as  the  head  advances  by  the  traction,  they 
become  placed  on  its  sides,  and  greatly  interfere  with  its  expul- 
sion during  the  last  period  of  the  labor.  When  the  contractions  of 
the  uterus  expel  the  child,  the  arms  are  born  in  the  position  originally 
assumed  by  them ;  but  if  traction  be  made,  its  influence  is  exerted 
only  on  the  body,  and  there  is  invariably  a  tendency  of  the  arms  to 
rise  along  the  sides  of  the  head,  because  the  pressure  of  the  uterine 
fundus  is  then  no  longer  exerted  upon  them  to  keep  them  in  place. 
Consequently,  it  is  bad  practice  in  ordinary  cases,  to  bring  down 
the  feet,  as  well  as  to  attempt  to  hasten  labor  by  making  artificial 
traction.  . 

In  these  preternatural  cases,  the  physician  should  be  more  attentive 
to  the  progress  of  labor  than  in  natural  cases,  being  careful,  however, 
not  to  alarm  his  patient  by  an  unnecessary  display  of  over-anxiety,  or 
officiousness,  nor  to  make  any  injudicious  attempts  to  advance  its 
progress  during  the  early  stage.  During  the  escape  of  the  breech 
from  the  vulva,  the  perineum  becomes  greatly  distended,  and  it 
should  be  steadily  supported  in  order  to  prevent  the  too  rapid  advance 


PRETERNATURAL    LABOR — PELVIC    PRESENTATIONS.  439 

of  the  pelvic  extremity,  as  well  as  to  impart  a  motion  to  it  in  the 
direction  of  the  inferior  part  of  the  pelvic  axis,  and  without  which 
movement  much  delay  would  be  occasioned.  Dr.  Collins  remarks: 
"  The  most  critical  part  of  the  delivery,  should  much  delay  take  place, 
is  during  the  passage  of  the  head,  which  pressing  continuously  on  the 
funis  speedily  deprives  the  child  of  life.  To  guard  against  this, 
therefore,  the  breech  should  be  permitted  to  pass  slowly  and  unas- 
sisted, so  as  gradually  and  perfectly  to  dilate  the  soft  parts,  thereby 
greatly  facilitating  the  completion  of  the  labor."  When  the  contrac- 
tions of  the  uterus  are  sufficient  to  expel  the  fetus,  however  slowly,  no 
interference  whatever  is  required;  it  is  only  when  the  breech  has  so 
far  advanced  externally  as  to  permit  the  cord  to  be  reached,  that  any 
aid  will  be  needed.  The  cord  must  be  drawn  down  a  little,  in  order 
to  prevent  it  from  being  broken  off,  as  well  as  to  prevent  its  vessels 
from  being  stretched.  The  umbilical  arteries  of  the  cord  run  in  a 
tortuous  manner  around  the  vein,  and  consequently  any  stretching 
of  the  cord  would,  by  diminishing  their  caliber,  as  effectually  check 
the  circulation,  as  from  direct  pressure  of  the  head  while  in  the 
pelvis;  hence,  by  keeping  a  loop  of  the  funis  slack,  we  prevent  any 
danger  to  the  child  from  tension  of  the  cord  during  the  advance  of 
the  body.  After  the  cord  has  been  placed  within  reach,  the  necessity 
for  interference  can  always  be  determined  by  the  character  of  its 
pulsations;  if  these  be  strong,  haste  is  not  required;  if  they  become 
feeble,  irregular,  or  intermittent,  assistance  must  not  be  delayed,  and 
the  body  of  the  child  may  be  brought  down  during  a  pain ;  if  they 
have  ceased,  an  indication  of  the  child's  death,  the  case  should  be  left 
to  nature.  A  soft  napkin  should  always  be  wrapped  around  the 
child's  body,  as  soon  as  the  feet  have  been  delivered,  which  will 
protect  its  surface  from  being  injured,  as  well  as  enable  the  physician 
to  hold  it  more  firmly  when  performing  any  manipulation  which  may 
be  required. 

The  passage  of  the  shoulders  through  the  external  parts  must  be 
carefully  attended  to,  and  if  they  do  not  present  favorably  at  the 
outlet,  rotation  should  be  made,  to  bring  the  proper  one  under,  or 
nearly  under,  the  pubic  arch,  and  the  other  into  the  cavity  of  the 
sacrum.  If  the  arms  remain  by  the  side  of  the  child,  there  will  be  no 
delay  in  the  expulsion  of  the  shoulder,  but  if  they  have  become  ele- 
vated, the  advance  of  the  shoulders  and  head  will  be  very  much,  if  not 
entirely,  retarded.  To  obviate  this,  one  or  two  fingers  are  to  be 
passed  along  the  arm,  as  near  as  possible  to  the  elbow,  when  the  elbow 
must  be  drawn  downward  and  forward,  across  the  face  and  chest,  until 


440  KING'S  ECLECTIC  OBSTETRICS. 

it  arrives  at  the  outlet;  one  arm  having  been  liberated,  the  other  may 
be  drawn  down  with  but  little  difficulty.  The  easiest  way  of  effecting 
the  descent  of  the  arms,  is  to  begin  with  the  one  nearest  to  the 
perineum,  and  to  draw  downward,  and  anteriorly  over  the  face  and 
chest  of  the  child ;  if  the  force  be  directly  downward,  or  toward 
the  back  of  the  child,  or  be  made  with  suddenness  or  violence,  the 
arm  may  be  broken  or  dislocated,  and  the  soft  parts  of  the  mother  be 
considerably  injured.  The  blunt  hook  has  been  advised  in  these 
cases,  but  I  see  no  necessity  for  it,  as  the  arms  may  always  be  reached 
by  the  fingers. 

The  shoulders  and  arms  having  escaped,  the  situation  of  the  head 
must  be  ascertained  by  an  examination.  For  this  is  the  critical  period, 
in  which  the  child  is  subject  to  great  peril  from  the  following  causes, 
and  in  wrhich  its  life  or  death  is  determined  in  a  few  seconds: — 1, 
compression  of  the  cord ;  2,  the  uterus  being,  as  it  were,  in  an  empty 
state,  diminishes  in  size,  which  interferes  with  and  prevents  a  full  flow 
of  blood  to  and  from  the  placenta,  thereby  lessening  the  aeration  of 
the  fetal  blood  to  a  greater  or  lesser  extent;  3,  the  reduction  in  size  of 
the  uterus  is  followed  by  a  detachment  of  the  placenta  from  the  uterine 
wall ;  4,  the  head  now  being  nearly  or  entirely  out  of  the  uterus,  is  no 
longer  under  the  influence  of  its  expulsive  action — its  vis  &  tergo — 
and  unless  this  lost  force  is  compensated,  the  child  will  certainly  be 
lost.  If  no  improper  interference  has  been  attempted,  all  these  dan- 
gers may  generally  be  avoided  by  the  straining  or  bearing-down  efforts 
of  the  diaphragm,  abdominal  muscles,  etc. 

During  the  progress  of  the  labor  the  accoucheur  must  so  manage, 
if  required,  as  may  occasionally  be  the  case  in  the  second  sacro-iliac 
positions,  that  when  the  head  is  in  the  pelvis,  the  face  will  be  directed 
toward  the  hollow  of  the  sacrum.  When  this  is  effected,  either  natu- 
rally or  artificially,  he  will  elevate  the  child's  body  toward  the  maternal 
abdomen,  so  as  to  bring  the  long  diameter  (mento-occipital)  of  its  head 
in  correspondence  with  the  axis  of  the  inferior  strait ;  and  should  the 
chin  have  departed  from  the  breast,  he  will  introduce  two  fingers  and 
place  them  upon  the  child's  upper  jaw,  and  by  gentle  pressure  depress 
the  chin  upon  the  breast,  thus  facilitating  the  expulsion  of  the  head  by 
presenting  a  shorter  diameter  of  the  head  to  the  inferior  strait ;  and, 
if  necessary,  the  flexion  may  be  still  farther  facilitated  by  parsing  a 
finger  or  two  behind  the  symphysis  pubis,  for  the  purpose  of  pushing 
the  occiput  somewhat  upwardly  at  the  same  time  that  the  chin  is  being 
depressed.  At  this  time,  the  head,  being  freed  from  the  uterus,  is  not 
influenced  by  its  contractions,  and  the  auxiliary  aid  of  the  abdominal 


PRETERNATURAL    LABOR PELVIC   PRESENTATIONS.  441 

muscles,  etc.,  will  be  required  to  terminate  the  delivery ;  consequently, 
instead  of  waiting  for  a  pain,  the  patient  should  be  urged  to  bear 
down,  to  use  her  utmost  effort  in  bearing  down,  that  the  head  may  be 
expelled,  for  any  delay  will  endanger  the  life  of  the  child,  from  the 
continued  pressure  of  the  head  upon  the  cord,  etc.  Assistance  may 
likewise  be  given,  by  applying  gentle  extractive  force  to  the  shoulders 
in  the  direction  of  the  axis  of  the  inferior  strait,  bearing  in  mind, 
however,  that  an  excessive  amount  of  such  force,  will  seriously  injure 
the  child's  neck.  But  no  force  whatever  must  be  employed  that 
would  so  far  stretch  the  neck  as,  in  the  least,  to  affect  the  upper  part 
of  the  spinal  cord.  Should  a  delay  in  the  passage  of  the  head  occur, 
the  child  may  be  frequently  saved,  by  introducing  a  finger  into  its 
mouth  to  remove  any  mucus  which  may  be  there,  and  then  "pass  two 
fingers  upward  until, they  reach  the  two  maxillary  bones,  and  cover 
the  nose ;  by  doing  this,  the  backs  of  the  fingers,  pressing  the  perin- 
eum backward,  serve  to  keep  an  open  communication  with  the  air,  and 
the  child  can  breathe  very  well  until  the  expulsive  efforts  come  on." — 
(Meigs.)  [A  flat,  flexible  tube  introduced  into  the  mouth  of  the  child, 
has  also  been  advised,  for  the  same  purpose.]  This  author  also  recom- 
mends the  forceps  to  be  within  reach  in  all  pelvic  presentations,  feeling 
well  assured  that  he  has  saved  several  lives  which  would  have  been 
lost  but  for  this  precaution  ;  I  am  satisfied  that  this  course  is  not  only 
wise  and  prudent,  but  that  a  resort  to  the  forceps  in  all  cases  of  delay 
in  the  delivery  of  the  head,  in  which  the  pulsations  of  the  cord  are 
becoming  feeble,  will  result  in  benefit  to  both  the  child  and  mother. 

O  ' 

In  these  cases,  the  practitioner  must  act  promptly,  for  a  few  moments' 
delay  may  prove  fatal  to  the  child.  It  should,  however,  be  stated 
here,  that  the  forceps  will  not  be  so  frequently  required  in  those  cases 
in  which  the  head  is  at  the  superior  strait,  and  in  which  the  bearing- 
down  efforts  of  the  woman  are  insufficient,  as  has  been  generally  rep- 
resented. If  the  accoucheur  or  an  assistant,  will  make  the  bearing- 
down  efforts,  by  placing  his  hands  upon  the  inferior  portion  of  the 
abdomen  so  as  to  make  strong  pressure  upon  the  fetal  head,  he  can 
supply  the  required  degree  of  a  vis  a  tergo,  and  thus  obviate  the 
necessity  for  the  application  of  forceps.  The  forceps,  I  consider 
useful  in  breech  presentations,  only  after  the  head  has  passed  through 
the  brim  into  the  pelvic  cavity,  the  expulsive  efforts  being  insufficient 
for  its  delivery.  If,  however,  the  child  be  dead,  as  known  by  the 
cessation  of  pulsation  in  the  cord,  and  the  head  be  very  large,  or  some 
obstacle  presents  rendering  it  very  difficult  to  extract  with  the  forceps, 
the  perforator  may  be  introduced  behind  one  or  both  ears,  for  the  pur- 


442  KING'S  ECLECTIC  OBSTETRICS. 

pose  of  lessening  the  size  of  the  head,  and  thus  terminating  the  labor. 
The  head  being  born,  the  rest  of  the  labor  will  be  managed  as  in 
natural  labors. 

When  the  uterine  contractions  become  inefficient,  previous  to  the 
expulsion  of  the  breech,  or  when,  from  any  cause,  a  quick  delivery  is 
demanded,  one  or  two  fingers  may  be  passed  up  and  hooked  into  the 
groin,  and  steady  and  gentle  traction  be  made,  in  the  proper  direction, 
during  the  presence  of  a  pain ;  the  pains  may,  likewise,  be  rendered  more 
efficient  by  compressing  or  manipulating  the  uterine  fundus  through  the 
abdominal  walls;  by  the  internal  administration  of  Sulphate  of  Quinia; 
or  the  administration  of  Macrotys  may  stimulate  the  uterus  to  more 
powerful  contraction;  the  small  dose  may  be  repeated  every  half- 
hour  until  the  desired  result  is  produced.  Sometimes  a  few  doses 
of  the  Parturient  Balm  may  be  administered,  but  on  no  account 
is  Ergot  to  be  given  in  a  case  of  pelvic  presentation.  For  the  purpose 
of  extracting  the  breech,  the  fillet  and  blunt  hook  have  been  recom- 
mended— these  may  sometimes  be  useful,  but  great  care  is  required  in 
using  them,  lest  the  thighs  of  the  child  be  fractured.  And  it  must 
never  be  lost  sight  of,  that  whenever  extracting  force  is  employed,  it 
should  always  be  made  in  the  direction  of  the  axis  of  the  pelvic  cavity, 
according  to  the  part  at  which  resistance  is  offered,  whether  the  force 
be  made  with  the  hand  or  fingers,  or  with  an  instrument. 

The  most  difficult  cases  of  breech  deliveries  are  those  in  which  the 
sacrum  of  the  child  is  directed  posteriorly,  or  toward  the  maternal 
sacrum,  and  during  the  descent,  rotation  has  not  been  effected,  as  may 
happen  in  the  second  sacro-iliac  positions;  in  consequence,  when  the 
head  reaches  the  inferior  strait,  the  face  of  the  child  will  be  to  the 
pubis,  and  its  occiput  to  the  sacrum.  This  will  occasion  considerable 
difficulty  in  the  delivery  of  the  head,  beside  being  a  very  dangerous 
situation  for  the  child.  A  complete  rotation  of  the  child's  body,  so  as 
to  reverse  the  positions,  and  bring  the  face  eventually  to  the  hollow 
of  the  sacrum,  must  be  produced,  either  spontaneously,  or  by  the 
management  of  the  accoucheur.  In  these  second  sacro-iliac  positions,, 
when  the  breech  is  low  in  the  pelvis,  and  not  yet  delivered,  and  the 
desired  rotation  has  not  taken  place,  two  or  three  fingers  may  be 
introduced  for  the  purpose  of  forcing,  by  steady  and  continuous  pres- 
sure, that  hip  which  is  situated  the  most  anteriorly,  toward  the  pubic 
symphisis:  and  the  delivery  of  the  hips  being  achieved  in  this  position, 
they  may  be  enveloped  in  a  soft  napkin,  and  as  the  pains  expel  the 
body,  the  accoucheur  will  gradually  continue  the  rotation  in  such  » 


PRETERNATURAL    LABOR PELVIC    PRESENTATION.  443 

manner  that  the  face  will  be  in  the  desired  position  at  the  time  it 
reaches  the  lower  part  of  the  pelvic  cavity.  And  in  effecting  this 
change,  should  the  pains  urge  the  body  too  rapidly  onward,  he  must, 
by  counter-pressure,  prevent  its  too  hasty  exit,  until  the  rotation  is 
satisfactorily  accomplished. 

Sometimes  the  body  of  the  child  will  be  held  by  the  womb  so  forcibly, 
during  a  pain,  that  the  rotation  can  not  be  performed;  the  practitioner 
should  then  operate  during  the  absence  of  pain,  first  pushing  the 
child's  body  upward  as  far  as  possible,  and  then  giving  to  it  a  compound 
movement,  by  drawing  it  downward  and  at  the  same  time  rotating  it. 
By  this  manipulation,  the  arms  are  prevented  from  passing  up  by  the 
sides  of  the  head. 

Should  the  head,  however,  have  reached  the  inferior  strait  with  the 
face  to  the  pubis,  the  practitioner  will  cause  the  female  to  lie  on  her 
back,  her  hips  being  brought  over  the  edge  of  the  bed,  and  the  feet 
supported  on  chairs  by  two  assistants.  As  soon  as  the  shoulders  are 
delivered,  an  assistant  will  carry  the  body  of  the  child  backward,  while 
the  accoucheur  will  press  the  perineum  back,  with  one  hand,  to  prevent 
its  forcing  the  throat  against  the  pubis,  and  with  the  other  he  will 
bring  down  the  chin,  either  by  introducing  two  fingers  into  the  mouth, 
or  better,  by  placing  them  upon  the  upper  jaw.  The  chin  having 
been  thus  depressed,  the  woman  must  be  urged  to  bear  down  forcibly, 
in  order  to  facilitate  the  expulsion  of  the  head.  Should  this  method 
fail,  the  forceps  will  probably  be  required,  or  perhaps  the  perforator. 

Notwithstanding  the  rules  just  laid  down  for  bringing  the  occiput 
under  the  pubic  arch,  it  must  always  be  borne  in  mind,  that,  whether 
the  position  be  a  first  or  second  sacro-iliac,  if  there  has  been  -no  im- 
proper interference  with  the  labor,  the  rotation  of  the  head,  in  the 
pelvic  cavity,  will  almost  always  effect  the  desired  results,  naturally, — 
bringing  the  occiput  under  the  pubic  arch  without  any  artificial  assist- 
ance. "  It  appears  to  be  a  law  in  nates  presentations,  that  whatever  may 
be  the  direction  of  the  child  (first  or  second  sacro-iliac)  at  the  begin- 
ning of  labor,  it  will  always,  if  not  interfered  with,  be  found  with  its 
anterior  surface  turned  toward  one  or  other  of  the  sacro-iliac  sym- 
physes  when  the  thorax  or  the  shoulders  are  beginning  to  pass  through 
the  outlet  of  the  pelvis."  (Rigby.} — Relative  to  the  sacrum  of  the 
child  being  directed  toward  the  maternal  abdomen,  another  writer 
observes :  "  It  is  very  desirable  the  child  should  be  delivered  in  this 
position,  as  it  renders  the  getting  away  of  the  head  much  less  diffi- 
cult ;  yet  where  there  has  been  no  interference  by  the  attendant  in  the 
previous  part  of  the  labor,  he  will  rarely  find  it  necessary  to  subse- 


444  KING'S  ECLECTIC  OBSTETRICS. 

quently  alter  the  child's  position,  the  breech  naturally  making  the 
turn,  above  alluded  to,  in  its  passage."  (Collins.} 

I  have  stated  heretofore,  that  it  is  bad  practice,  in  breech  presenta- 
tions, to  bring  down  the  feet ;  still,  there  may  be  instances  where  this 
will  be  demanded,  and  where  it  will  become  necessary,  also  to  employ 
some  forcible  traction,  in  order  to  expedite  delivery.  Thus,  in  cases 
where  the  breech  is  large  and  the  pelvis  narrow,  it  may  be  almost 
impossible  for  delivery  to  be  effected,  without  some  interference  of  this 
kind ;  accidents  may  also  occur,  at  the  commencement  of  labor,  which, 
by  jeopardizing  the  life  of  the  mother,  require  a  hastening  of  the 
labor,  as  in  convulsions,  hemorrhage,  etc.  But  should  these  occur 
while  the  os  u'teri  is  undilated,  temporizing  and  palliative  measures 
only  can  be  employed,  and  no  attempts  whatever  should  be  made  to 
introduce  the  hand  within  the  uterus  for  the  purpose  of  bringing  down 
the  feet. 

Should  these  accidents  occur  when  the  breech  is  low  in  the  pelvis  but 
still  within  the  uterus,  we  must  be  guided  by  the  circumstances.  If  the 
os  uteri  be  rigid,  no  attempts  to  introduce  the  hand  must  be  made 
until  the  rigidity  is  overcome  :  if  it  be  dilatable  and  in  proper  condi- 
tion the  hand  may  be  introduced,  whether  the  membranes  be  ruptured 
or  not,  and  the  feet  brought  down. 

If  interference  is  demanded  after  the  breech  has  been  expelled  from 
the  uterus,  the  feet  must  not  be  brought  down,  unless  the  pelvis  be 
large,  or  the  breech  be  small,  and  unless  the  pains  have  ceased  to  be 
efficient.  In  this  case,  if  the  breech  be  very  low  in  the  pelvis,  a  finger 
may  be  passed  above  one  or  both  groins,  and  during  the  presence  of 
pain,  traction  may  be  made  in  the  direction  of  the  pelvic  axis.  If  the 
breech  can  not  be  delivered  by  this  means,  the  fillet  may  be  employed, 
and  if  this  can  not  be  applied,  the  blunt  hook  must  be  resorted  to. 

As  remarked  in  a  previous  chapter,  knee  and  feet  presentations 
are  mere  deviations  from  the  breech,  the  labors  being  more  painful 
and  difficult,  with  greater  risk  to  the  child,  but  requiring  a  similar 
management.  When  the  KNEE  presents,  it  may  be  mistaken  for  an 
elbow,  but  may  be  distinguished  from  it  by  the  rounded  patella  with 
its  flat  surface,  and  which  is  more  or  less  movable  on  the  con dy lea 
of  the  thigh  bone;  the  olecranon  of  the  elbow  is  pointed  and  sharp- 
not  flat,  like  the  patella,  and  is  not  movable.  NsegSle  observes  that 
the  u  knee  is  thicker,  has  two  prominences,  and  a  depression  between 
them,  while  the  elbow  is  thinner,  and  presents  to  the  feel,  between  the 
two  prominences,  a  projection  (olecranon),  in  which  it  seems  to  end." 


PRETERNATURAL    LABOR — PELVIC    PRESENTATIONS. 

The  shoulder  has  but  one  prominence  or  tuberosity,  "  from  which  the 
bony  ridges  of  the  clavicle  and  scapular  spine  may  be  traced." 

In  knee  presentations  it  is  always  advisable  to  convert  them  into 
footling  cases,  which  may  be  effected  by  pushing  the  fetus  upward 
during  the  absence  of  pain,  so  that  sufficient  space  may  be  gained  to 
bring  down  the  feet. 

A  FOOT  may  be  determined  from  a  hand,  by  its  rounded  instep,  its 
prominent  heel,  the  toes  being  all  in  one  line,  and  no  one  of  the  digits 
being  an  opponent  to  the  others :  the  hand  has  no  rounded  instep,  no 
prominent  heel,  the  digits  are  not  all  in  one  line,  there  is  a  flattened 
palm,  the  fingers  longer  than  the  toes,  not  all  of  the  same  length,  and 
the  thumb  opposed  to  the  fingers.  The  foot  is  also  longer  than  the 
hand,  and  its  sole  flatter,  and  the  presence  of  the  heel,  with  the  ankle- 
bone  on  each  side,  will  distinguish  it  from  the  hand  and  wrist. 

When  one  foot  only  descends,  we  should  determine  whether  it  be 
the  right  or  left  •  but  it  is  not  always  so  easy  to  detect  the  position  of 
the  child  by  the  foot,  at  least,  not  until  the  hips  have  engaged  in  the 
superior  strait.  But  when  both  feet  come  down,  crossing  each  other, 
the  toes  will  lie  in  the  direction  of  the  child's  abdomen  or  anterior 
surface.  In  knee  or  footling  cases,  as  with  those  of  the  nates, 
nothing  can  be  done  by  the  attendant,  except  to  patiently  observe 
nature's  operations,  and  to  quickly  detect  any  departure  from  their 
normal  course.  The  labor  will  be  slower  and  more  painful  to  the 
mother  than  if  the  nates  had  presented,  but  its  management  will  be 
exactly  the  same,  unless,  as  ascertained  from  the  diminution  of  the 
pulsations  in  the  cord,  or  otherwise,  the  child's  life  becomes  endangered, 
when  the  delivery  must  be  expedited  by  the  means  already  referred  to. 

In  cases  of  breech  presentation,  various  means  should  be  in  readi- 
ness, as  a  warm  bath,  etc.,  to  resuscitate  the  child,  should  animation 
be  suspended ;  its  limbs  and  genitals  should  also  be  carefully  examined 
before  leaving  it ;  and  if  they  present  appearances  of  injury,  a  proper 
dressing  should  be  applied,  in  accordance  with  the  nature  of  the  case. 
If  the  child  be  born  in  a  state  of  defective  vitality,  some  of  the 
measures  looking  to  resuscitation  may-  be  pursued,  according  to 
circumstances. 

Rigidity  of  the  os  uteri,  pelvic  tumors  or  deformities,  and  other 
circumstances  which  may  also  be  present  in  vertex  presentations, 
occasioning  difficult  labor,  must  be  treated  as  directed  under  the 
head  of  Difficult  Labor. 


446  KING'S  ECLECTIC  OBSTETRICS. 

CHAPTER    XXXIV. 

OF  PRETERNATURAL  LABOR — SHOULDER  PRESENTATIONS. 

IT  is  as  difficult  to  assign  a  sufficient  explanation  of  the  cause  of 
presentations  of  the  superior  extremities  as  of  those  of  the  pelvic. 
They  have  been  attributed  to  irregular  distension  of  the  uterus,  to 
uterine  obliquity,  to  irregular  contractions  at  an  early  period  of  labor, 
etc.,  and  they  may  have  existed  primarily.  Dr.  Rigby  remarks:  "We 
may,  therefore,  state  that  the  causes  of  arm  or  shoulder  presentation 
are  of  two  kinds,  viz.:  when  the  uterus  has  been  distended  by  an 
unusual  quantity  of  liquor  amnii,  or  when,  from  a  faulty  condition  of 
the  early  pains  of  labor,  its  form  has  been  altered,  and  with  it  the 
position  of  the  child."  Dr.  William  Leishman,  in  considering  the 
causes  of  transverse  presentations,  calls  attention  to  the  fact  that 
"Any  fault  or  deformity  in  the  structure  of  the- pelvic  brim,  which 
may  act  by  preventing  the  descent  of  the  head  into  the  cavity,  may 
turn  aside,  toward  the  iliac  fossa,  that  extremity  of  the  fetal  ovoid, 
when  the  shoulder  may  slip  down  and  take  its  place.  The  unfort- 
unate tendency  to  a  recurrence  of  this  presentation  in  women  who 
have  already  had  a  child  or  children,  presenting  by  the  superior 
extremity,  would  almost  seem  to  indicate  that  some  anatomical  peculi- 
arity of  the  parts  may  be  the  cause;  and  it  was  this  which  led 
Wigand  to  suppose  that  the  form  of  the  uterine  cavity  was  the  deter- 
mining cause,  and  that,  in  those  cases  in  which  cross-birth  occurred, 
the  transverse  diameter  of  the  uterus  was  in  the  first  instance  aug- 
mented, the  long  diameter  of  the  cavity  being  thus  relatively  dimin- 
ished." Still,  these  "cross-births,"  as  they  are  often  called,  are 
involved  in  much  obscurity ;  there  appears  to  be  a  natural  tendency 
to  them  with  some  women  (as  above  stated),  who  have  them  at  every 
labor. 

Previous  to  the  commencement  of  labor,  there  are  no  positive  signs 
by  which  we  can  determine  the  presentation  of  a  shoulder,  or  of  any 
part  of  the  body;  and  no  dependence  can  be  placed  in  an  unusual, 
figure  of  the  uterus,  as  ascertained  by  applying  the  hand  over  the 
abdomen.  A  transverse  presentation  of  the  fetus  may  be  suspected 
when  the  os  uteri  dilates  slowly,  when  the  membranes  protrude  into 
the  vagina  in  an  elongated  form,  when  the  presenting  part  is  beyond 


PRETERNATURAL  LABOR — SHOULDER  PRESENTATIONS.    447 

the  reach  of  the  finger,  and  when,  after  the  rupture  of  the  membranes, 
the  pains  cease  for  several  hours.  A  vaginal  examination  wUl  deter- 
mine the  correctness  of  our  suspicions,  as  well  as  inform  us  of  the 
position;  and  both  of  these  points  should  be  satisfactorily  ascertained 
before  any  interference  is  attempted  by  the  practitioner. 

I  have  already  remarked,  in  a  preceding  chapter,  that  there  are  two 
positions  for  each  shoulder,  viz.:  FIRST  LEFT  CEPHALO- 
ILIAC,  and  FIRST  RIGHT  CEPHALO-ILIAC  of  the  RIGHT 
SHOULDER,  and  SECOND  LEFT  CEPHALO-ILIAC,  and 
SECOND  RIGHT  CEPHALO-ILIAC  of  the  LEFT  SHOUL- 
DER; and  to  which  the  reader  is  referred  for  an  explanation  of  the 
situation  of  the  child  in  these  several  positions. 

DIAGNOSIS. — Previous  to  the  rupture  of  the  membranes,  the 
presenting  part  is  commonly  elevated  beyond  the  reach  of  the  practi- 
tioner's finger,  which  alone  should  lead  us  to  suspect  a  preternatural 
presentation;  but  it  may  always  be  felt  after  they  have  given  way; 
and  then  a  careful  examination  should  be  made,  that  no  doubts,  may 
exist  with  regard  to  the  nature  of  the  case.  This  should  be  satisfac- 
torily accomplished,  in  all  instances,  immediately  after  the  membranes 
have  ruptured,  and  if  necessary,  a  part  of  the  hand,  or  even  the  whole 
of  it,  should  be  introduced  into  the  vagina,  for  the  purpose  of  making 
a  correct  diagnosis.  Should  the  presenting  part  be  an  elbow  or  hand, 
it  may  be  felt  offering  at  the  mouth  of  the  uterus  before  the  rupture  of 
the  membranes;  and  sometimes,  after  a  hand  has  been  clearly  detected 
at  the  os  uteri,  it  has  subsequently  become  withdrawn,  and  the  vertex 
found  presenting.  The  shoulder  may  be  known  from  the  head  by  its 
being  less  bulky,  less  firm  and  resisting,  and  by  the  absence  of  sutures 
and  fontanelles;  from  the  breech,  by  the  absence  of  the  anus  and 
parts  of  generation,  and  by  being  not  so  large  and  less  fleshy.  The 
finger,  on  coming  in  contact  with  it,  first  detects  the  projecting  acro- 
mion,  in  front  of  which  will  be  felt  the  clavicle,  below  which  the  ribs 
and  intercostal  spaces  will  be  readily  made  out;  then  carrying  the 
finger  behind  the  acromial  process,  the  hard,  spinous  process  of  the 
scapula  will  be  detected,  the  surface  inferior  to  it  will  be  found  plane 
and  smooth,  terminating  below  in  the  acute  inferior  angle  of  the  scap- 
ula, which  i^  movable  and  will  permit  the  finger  to  pass  under  it. 
The  arm  may  also  be  felt  and  distinguished  from  the  thigh  by  its  size, 
and  sometimes  the  depression  in  the  neck  can  be  recognized.  Great 
care  must  be  taken  in  the  examination,  especially  when  a  hand  or 
arm  is  felt,  to  determine  whether  it  is  due  to  a  transverse  presenta- 


448  KING'S  ECLECTIC  OBSTETRICS. 

tion,  or  is  the  troublesome  complication  of  a  vertex  presentation ;  and 
to  positively  ascertain  these  matters  it  will  become  necessary  to  intro- 
duce the  fingers  or  the  hand  through  the  os  uteri.  It  is  likewise 
proper  to  learn  whether  the  shoulder  has  engaged  in  the  brim.  .  In 
these  cases  the  accoucheur  should  not  leave  his  patient  until  he  has 
clearly  satisfied  himself  both  of  the  presentation  and  the  position. 

Having  ascertained  the  case  to  be  a  shoulder  presentation,  the  next 
and  most  important  point  is  to  determine  which  shoulder  presents, 
and  its  position.  If  this  can  not  be  ascertained  at  an  early  stage  of 
the  labor,  it  always  can  in  time  to  be  remedied,  and  that  is,  when  the 
dilatation  will  admit;  this  may  be  effected  by  ascertaining  where  the 
fetal  head  lies,  and  the  situation  of  its  back.  The  side  to  which  the 
head  is  directed  may  be  known  by  the  axilla,  which  must  always  look 
in  an  opposite  direction  to  that  of  the  head;  thus,  if  the  axillary  space 
looks  toward  the  left  ilium  of  the  mother,  the  fetal  head  will  be  to  her 
right  ilium,  and  vice  versa.  The  direction  of  the  back  may  be  known 
by  the  scapula  and  vertebrae  behind,  and  the  clavicle,  ribs,  and  inter- 
costal spaces  before.  Should  there  be  the  least  doubt  relative  to  these 
points,  the  practitioner  should  not  hesitate  to  bring  down  an  arm  in 
order  to  assist  him  in  his  diagnosis,  as  it  will  occasion  no  difficulty  in 
the  operation  of  turning;  but  in  effecting  it  great  care  should  be 
taken  not  to  make  the  slightest  traction  upon  the  fetus. 

When  the  elbow  presents,  it  may  be  recognized  by  three  bony  prom- 
inences, viz.:  the  olecranon  and  the  two  condyles,  and  by  the  bend  of 
the  elbow  occasioned  by  the  flexion  of  the  fore-arm  upon  the  arm. 
The  position  of  the  fetal  head  may  also  be  known  readily,  being 
always  toward  the  side  opposite  to  that  in  which  the  elbow  is  directed ; 
and  the  fore-arm  usually  rests  upon  the  anterior  of  the  child's  body, 
as  just  remarked  above.  I  repeat,  should  there  be  the  least  doubt  as 
to  the  position,  or  the  presentation,  and  provided  the  membranes  have 
ruptured,  the  arm  may  be  carefully  brought  down,  making  no  trac- 
tion whatever  upon  the  fetus.  To  distinguish  a  knee  from  an  elbow 
has  already  been  explained  in  the  preceding  chapter. 

Sometimes  a  hand  will  hang  down  in  the  vagina,  or  even  out  at  the 
vulva,  and  be  mistaken  for  a  foot.  If  the  young  accoucheur  will 
accustom  himself  to  feel  and  handle  the  various  parts  of  a  newly-born 
child,  as  the  feet,  knees,  hands,  elbow,  shoulders,  etc.,  he  will  acquire 
a  ready  tact  in  diagnosticating,  which  will  prove  greatly  advantageous. 
We  may  learn  which  shoulder  presents  by  the  hand.  If  the  palmar 
surface  be  found  directed  toward  the  pubic  symphysis,  the  thumb 


PRETERNATURAL    LABOR — SHOULDER    PRESENTATIONS.         449 

turning  to  the  right  side  of  the  maternal  pelvis,  it  is  the  right  hand, 
«md  consequently  a  presentation  of  the  right  shoulder;  if  the  thumb 
turn  to  the  left  side,  it  is  the  left  hand,  and  left  shoulder  presentation. 
If  the  dorsal  surface  or  back  of  the  hand  be  directed  in  front,  the 
thumb  being  toward  the  right  side  of  the  pelvis,  it  indicates  the  pres- 
ence of  the  left  hand  and  shoulder;  if  the  thumb  be  toward  the  left 
side,  it  is  the  right  hand  and  shoulder  presenting.  The  head  is  always 
in  the  direction  of  the  thumb;  thus,  if  the  thumb  be  toward  the  left 
side,  the  head  will  be  in  the  left  iliac  fossa,  and  vice  versa;  if  the 
palmar  surface  of  the  hand  be  in  front,  the  child's  face  will  be  looking 
towards  its  mother's  abdomen ;  if  the  dorsal  surface  be  in  front,  the 
back  of  the  child  will  be  toward  the  maternal  abdomen. 

Having  ascertained  that  the  presentation  is  of  the  shoulder,  the 
practitioner  should  immediately  inform  the  husband  or  friends  that 
it  is  a  "cross-birth,"  and  explain  to  them,  without  any  reserve,  the 
necessity  for  interference,  and  the  hazards  to  the  child  as  well  as  to 
the  mother.  The  earlier  assistance  can  be  given  after  the  membranes 
have  ruptured,  or  after  the  os  uteri  has  fully  dilated,  the  better  will  it 
be  for  all  the  parties  concerned.  Delay,  after  these  conditions,  com- 
promises the  patient's  life,  as  each  pain  not  only  augments  in  severity, 
but  forces  the  shoulder  more  and  more  tightly  into  the  pelvis,  so  that 
the  woman  becomes  exposed  to  the  consequences  of  exhaustion,  or 
rupture  of  the  uterus,  while  the  child  is  lost  from  the  constant  press- 
ure. Whenever  it  is  possible,  council  should  be  had,  that  the  friends 
may  be  thoroughly  satisfied,  and  also  that  no  subsequent  censure  may 
be  attached  to  the  attendant,  should  serious  consequences  result.  The 
patient  should,  likewise,  be  informed  that  labor  can  not  proceed  with- 
out artificial  aid,  and  the  reason  made  known  to  her ;  and  this  should 
be  done  in  a  kind  and  gentle  manner,  carefully  avoiding  any  dis- 
couraging word,  look,  or  action.  But  this  communication  should  not 
be  made  to  her  until  we  are  about  to  commence  attempting  the  version. 

TREATMENT  OF  SHOULDER  PRESENTATIONS. 

When  a  shoulder  presentation  is  suspected. or  ascertained  previous 
to  the  rupture  of  the  membranes,  and  before  the  os  uteri  is  sufficiently 
dilated,  every  means  should  be  used  to  preserve  the  membranes 
entire;  examinations  should  be  made  with  care,  and  the  female  should 
be  kept  in  a  horizontal  position.  No  attempts  whatever  should  be 
made  to  force  the  hand  into  the  uterus  until  it  is  dilated  or  dilatable, 
and  even  then  not  until  the  position  is  satisfactorily  determined.  In 
29 


450  KING'S  ECLECTIC  OBSTETRICS. 

the  meantime,  the  rectum  should  be  evacuated  by  the  administration 
of  a  mild,  emollient  enema,  if  necessary,  and  the  bladder  by  a  cath-., 
eter;    for  the  operation  of  turning,  which  is  the  one  usually  recom- 
mended and  pursued  in  these  cases,  should  never  be  undertaken  until 
these  evacuations  have  been  effected  either  naturally  or  artificially. 

As  soon  as  the  os  uteri  has  become  dilated  to  the  size  of  half  a  dol- 
lar, sufficient  to  permit  the  introduction  of  the  hand,  it  being  also, 
together  with  the  vagina  and  soft  parts,  perfectly  soft  and  yielding, 
the  membranes  remaining  entire,  the  practitioner,  having  been  enabled 
to  clearly  diagnose  the  position,  may  carefully  proceed  to  effect  the 
operation  of  turning  the  child.  This  is,  in  fact,  the  most  favorable 
period  for  the  operation,  as  the  presence  of  the  amniotic  fluid  within 
the  cavity  of  the  uterus  not  only  admits  a  ready  introduction  of  the 
hand,  but,  by  floating  the  child,  permits  it  to  be  turned  in  any  direc- 
tion. The  practitioner  can  not  be  too  careful  as  to  the  time  when  he 
enters  a  hand  into  the  uterine  cavity:  if  he  makes  the  attempt  at  too 
early  a  period,  the  most  lamentable  results  wrill  follow;  if  it  be  too 
long  delayed,  the  hazards  and  difficulties  are  increased,  and  the  patient 
suffers  uselessly. 

The  position  and  presentation  having  been  clearly  ascertained,  the 
os  uteri  dilated,  soft  and  yielding,  with  no  rigidity  of  the  soft  parts, 
and  the  practitioner  having  waited  for  a  period  consistent  with  the 
integrity  of  the  membranes  and  the  preservation  of  the  liquor  amnii, 
it  would  be  unwise  to  wait  until  the  complete  dilatation  of  the  os 
uteri.  The  rectum  and  bladder  of  the  patient  having  been  previously 
evacuated,  she  must  be  placed  in  position  for  operating ;  lying  on  her 
back,  across  the  bed,  with  her  hips  brought  a  little  over  its  edge,  her 
feet  properly  supported  by  assistants,  so  as  to  flex  the  limbs  well,  and 
thus  favor  a  relaxation  of  the  abdominal  muscles,  is  probably  the 
position  more  often  chosen.  Some  operators  prefer  that  she  should  be 
on  her  knees  and  elbows,  while  others  favor  Sims'  position,  the  patient 
resting  on  her  left  side,  the  limbs  flexed,  and  the  nates  brought  con- 
veniently near  the  edge  of  the  bed.  She  should  by  no  means  be  ex- 
posed, but  should  be  co.vered  by  some  bed-clothing,  suitable  to  the 
temperature  of  the  season,  and,  for  the  purpose  of  receiving  discharges, 
a  thick  layer  of  cloths  should  be  placed  on  the  floor,  immediately  be- 
neath her. 

The  practitioner  will  now  remove  his  coat,  bare  his  arm  to  the 
elbow,  and  anoint  it  well  with  sweet  oil  or  lard ;  if  the  vagina  be  sim- 
ilarly anointed,  it  will  favor  the  easy  introduction  of  the  hand.  To 


PRETERNATURAL    LABOR SHOULDER    PRESENTATIONS.         451 

protect  himself  from  the  discharges,  a  sheet  or  apron  may  be  worn 
over  his  dress.  While  the  practitioner  is  thus  engaged,  an  assistant 
should  administer  an  anesthetic.  The  patient  should  he  brought  well 
under  its  influence;  it  not  only  produces  insensibility  to  pain,  but 
overcomes  spasmodic  action,  and  promotes  relaxation  and  dilatation, 
and  thus  facilitates  the  passage  of  the  hand,  and  serves  to  expedite  the 
version.  Everything  thus  prepared,  he  will  take  his  seat,  at  a  con- 
venient distance  for  operating,  between  the  patient's  limbs,  or  near 
the  side  of  the  bed,  according  to  the  position  assumed  by  the  patient; 
and  throughout  the  whole  operation  he  should  be  cool  and  deliberate, 
manifesting  no  haste,  excitement,  trepidation,  nor  hesitation. 

There  is  some  choice  of  the  hand  to  be  introduced  —  ihat  one 
should  always  be  used  which- can  the  most  conveniently  effect  the 
version;  and  the  common  rule  is,  to  use  the  hand  whose  palmar  sur- 
face would,  when  opened  within  the  uterine  cavity,  be  directed  to  the 
anterior  surface  of  the  child's  body.  Should  the  child's  hand  present, 
this  may  readily  be  ascertained  by  grasping  it  as  in  shaking  hands, 
and  that  hand  should  be  used  the  palm  of  which  comes  in  contact 
with  the  fetal  palm. 

It  is  not  unfrequently  the  case  that  the  contractions  of  the  uterus  so 
completely  benumb  the  hand  which  has  been  first  introduced,  that  the 
accoucheur,  being  unable  to  use  it,  is  compelled  to  withdraw  it,  and 
employ  the  other,  and  this  will,  of  course,  render  the  version  much 
more  difficult,  should  the  liquor  amnii  have  been  discharged.  Dr. 
Lee  advises  us,  in  all  cases,  no  matter  what  the  situation  of  the  trunk 
and  extremities,  to  pass  the  hand  up  between  the  anterior  and  shallow 
part  of  the  pelvis,  and  the  presenting  part  of  the  child. 

The  proper  period  for  passing  the  hand  within  the  vagina,  is  during 
a  pain;  the  fingers  may  be  held  together,  in  a  conical  form,  and  thus 
slowly  introduced,  or,  two  fingers,  then  three,  four,  and  lastly  the 
thumb,  strongly  flexed  into  the  palm,  may  be"  passed  within  the 
vulva;  while  passing  the  vaginal  sphincter  considerable  pain  will  be 
produced,  but  this  will  be  materially,  if  not  entirely,  lessened  after 
the  hand  has  entered  the  vagina.  The  hand  may  now  rest  stationary 
for  a  short  time,  to  produce  toleration  of  its  presence  as  well  as  to 
dilate  the  parts.  Its  introduction  ivithin  the  uterine  cavity,  must  be 
during  the  absence  of  pain;  an  attempt  to  pass  it  within  the  womb 
during  a  pain  would  probably  rupture  the  membranes,  and  allow  the 
amniotic  fluid  to  escape  before  the  vagina  was  sufficiently  plugged  up 
by  the  arm  to  prevent  it.  The  fingers  are  to  be  passed  within  the  os 


452 


KING'S    ECLECTIC    OBSTETRICS. 


FIG.  62. 


uteri  in  a  conical  form,  gently  and  slowly  dilating  this,  from  time  to 
time,  by  separating  them,  and  then  again,  with  the  hand  in  the  cone 
shape,  carefully  and  gently  pushing  it  upward  until  it  is  fully  within 
the  uterine  cavity.  If  the  presence  of  the  hand  has -not  excited  uter- 
ine contractions,  followed  by  rupture  of  the  membranes,  the  bag  of 
waters  should  rest  on  the  hand,  and  be  passed  up  as  far  as  possible 

before  rupturing  them;  the  presenting 
part  should  also  be  pushed  upward  and 
to  the  left  or  right,  according  as  the 
head  may  be  on  the  left  or  right  side  of 
the  uterus.  (Fig.  62.)  While  the  hand 
is  entering  the  os  uteri,  the  uterus  should 
be  kept  steady  by  the  other  hand  of  the 
operator,  or,  what  is  much  better,  the 
assistant  should  place  his  hand  on  the 
abdomen,  over  the  fundus  of  the  womb, 
to  steady  the  organ,  and  at  the  same 
time  to  maintain  a  gentle  pressure  down- 
ward, to  keep  the  os  uteri  within  the 
strait.  Usually,  the  membranes  give  way  as  the  hand  is  passing 
within  the  uterine  cavity,  even  before  the  feet  are  reached,  in  which 
case  the  hand  and  arm  must  be  pressed  firmly  forward  to  plug  up  the 
orifice,  lest  the  amniotic  fluid  escapes,  thereby  causing  the  version  to 
be  more  difficult. 

Should  a  pain  come  on  during  the  entrance  of  the  hand  into  the 
uterus,  it  must  be  kept  perfectly  still,  and  when  within  the  cavity  of 
the  womb  it  should  be  opened  and  made  to  cover  the  body  of  the 
child  whenever  uterine  contractions  come  on ;  for  any  attempts  at 
moving,  or  resisting  the  action  of  the  organ  at  this  time  might  oc- 
casion its  rupture.  The  membranes  having  been  ruptured,  the  hand 
enters  into  the  cavity  of  the  ovum,  along  the  anterior  surface  of  the 
child,  and  should  be  passed  up  to  the  umbilicus,  where  the  funis  will 
be  felt,  and  in  the  neighborhood  of  which  a  foot  will  generally  be 
found.  Having  reached  a  foot,  secure  it  between  two  fingers,  and 
search  for  the  other;  and  if  the  contractions  come  on,  the  hand  must 
be  opened  and  clasped  over  the  child's  body.  If,  after  a  reasonable 
time,  the  other  foot  can  not  be  found,  the  version  may  be  accom- 
plished by  the  one  foot,  being  certain,  however,  that  it  is  a  foot  before 
attempting  the  change.  Frequently,  the  contractions  of  the  uterus 
are  so  severe  that  the  hand  of  the  operator  becomes  cramped,  numbed,. 


PRETERNATURAL  LABOR — SHOULDER  PRESENTATIONS.    453 

or  extremely  painful,  and  its  nicer  tact  of  feeling  becomes  so  impaired 
that,  without  the  greatest  care,  he  may  confound  a  hand  with  a  foot. 
On  this  point  be  exceedingly  cautious.  We  are  advised  by  Dr.  Rud- 
ford,  of  Manchester,  England,  who  has  had  much  experience  in  diffi- 
cult cases  of  obstetrics,  "  never  to  bring  down  more  than  one  foot  in 
the  manual  operation  of  turning;  because  the  other  thigh,  being  flexed 
upon  the  abdomen,  offers  a  larger  circumference  than  if  it  were  ex- 
tracted, and  thus  prepares  the  passages  for  the  more  easy  transit  of  the 
shoulders  and  head.  The  advantage  of  this  practice  consists  in  its 
affording  greater  safety  to  the  child;  the  disadvantage,  in  its  creating 
more  difficulty  in  accomplishing  the  evolution."  (Ramsbotham.}  The 
late  Professor  Meigs  observes,  in  his  Obstetrics :  "  At  length,  after 
more  or  less  research,  one  or  both  feet,  or  a  knee,  is  found ;  and 
whether  it  be  one  or  the  other,  it  should  be  taken  hold  of;  for  it  is 
nearly  a  matter  of  indifference  whether  it  be  one  foot  or  both,  or  one 
knee,  that  is  used  as  the  point  on  which  to  act  in  turning  the  child. 
Dr.  Collins  remarks,  on  this  point,  that  '  it  is  quite  sufficient  to  bring 
down  one  foot/  and  I  find  that  Dr.  Simpson,  of  Edinburgh,  is  of  the 
same  opinion  —  deeming  it  far  more  injurious  to  make  perverse 
attempts  at  exploration,  than  to  deliver  by  one  foot  only.  I  say, 
nearly  a  matter  of  indifference,  because,  the  object  being  to  turn  the 
child  as  soon  as  practicable,  with  proper  caution  it  may  be  effected  in 
either  of  these  ways;  it  is  always  desirable  to  get  the  hand  out  of  the 
uterus  as  soon  as  may  be,  and  it  is  far1  better  to  turn  by  one  foot  or  by 
a  knee,  than  to  incur  the  risk  of  laceration  or  contusion  of  the  organ 
by  a  tedious  search  alter  the  foot,  which,  if  it  be  not  originally  near 
its  fellow,  is  very  hard  to  be  found  by  any  search  for  it.  The  inex- 
perienced student  can  have  little  notion  of  the  extreme  difficulty  there 
is  to  move  the  hand  about  while  it  is  compressed  betwixt  the  womb 
and  the  child;  a  short  experiment  of  this  difficulty  would  suffice  to 
convince  him  of  the  propriety  of  the  foregoing  directions.  If  he 
should  use  the  knee  as  a  point  of  traction,  it  would  be  very  easy, 
when  the  version  is  nearly  complete,  to  draw  the  foot  down.  If  he 
use  only  one  foot  to  turn  by,  he  will  have  nearly  all  the  proposed 
advantage  of  the  breech  presentation,  combined  with  the  greater 
facility  enjoyed  in  manipulating  in  the  footling  case — that  is  to  say, 
he  will  have  the  abundant  dilatation,  and  the  power  of  traction  of  the 
limb.  It  sometimes  happens  that  a  foot  is  met  with  close  to  the 
orifice;  so  that,  even  without  carrying  the  hand  within  the  uterus, 
the  foot  can  be  hooked  down  by  means  of  one  or  two  fingers,  as  has 


454  KING'S  ECLECTIC  OBSTETRICS. 

been  done  by  Dr.  Robert  Lee,  of  London."  It  will  be  observed,  by 
the  following  from  Dr.  William  Leishman,  Professor  of  Midwifery 
in  the  University  of  Glasgow,  whose  views,  while  more  modern,  are  not 
especially  different  from  those  of  the  older  writers,  "much  argument 
has  been  wasted  as  to  the  propriety  of  bringing  down  one  leg  or  two. 
The  sound  rule  in  practice  is,  that  when  we  succeed  in  securing  one 
foot,  we  should  never  pause  to  search  for  the  other;,  as  one  is  all  that 
is  necessary;  unless,  perhaps,  in  cases  of  pelvic  deformity.  Nay, 
more  than  this,  the  descent  of  one  leg  has  a  positive  advantage  as 
compared  with  two,  as  thus,  by  increasing  the  diameter  of  the  pelvis 
of  the  child,  the  parts  are  more  thoroughly  dilated,  so  as  to  admit  of 
the  ultimate  passage,  rapidly,  and  with  comparative  safety,  of  the 
head  of  the  child.  And,  as  this  is  the  stage  at  which  the  life  of  the 
child  is  most  frequently  compromised,  it  is  assumed  that  by  abridging 
its  duration,  fetal  life  in  the  aggregate  must,  by  this  process,  be  saved. 
Still,  when  a  very  rapid  delivery  is  desired,  the  operator  know's  that 
he  has  a  better  and  more  efficient  hold  upon  two  limbs  than  he  can 
have  upon  one;  and  he  will,  therefore,  very  naturally,  bring  down 
both  when  they  are  within  easy  reach ;  but,  when  the  discovery  and 
seizure  of  the  other  limb  involves  extra  effort  or  delay,  not  even  in 
such  a  case  as  this  should  he  be  otherwise  than  content  with  what  he 
has  already  achieved.  The  foot  or  knee  which  is  lowest  in  the  womb 
or  easiest  of  access  should  at  once  be  seized;  but,  in  a  transverse 
presentation,  there  is  no  doubt  that  turning  will  be  more  easily 
effected  when  we  seize  the  leg  of  the  side  opposite  to  the  presenting 
shoulder."  It  will  thus  be  perceived  that  the  most  eminent  accouch- 
eurs of  this  country  and  Great  Britain  are  opposed  to  any  lengthy 
search  after  both  feet,  in  cases  of  turning,  and  my  own  experience  is 
•in  favor  of  performing  version  by  one  foot  when  there  is  any  consid- 
erable delay  or  difficulty  in  securing  both. 

If  it  be  possible  to  select  a  foot,  we  should  take  that  which  is 
opposite  to  the  presenting  hand  or  elbow,  and  which  will  be  situated 
more  toward  the  anterior  part  of  the  pelvis.  The  period  for  effecting 
the  version  is  during  the  absence  of  pain,  and  any  attempts  to  turn 
during  a  pain  will  not  only  be  found  nugatory,  but  may  be  productive 
of  serious  consequences.  While  the  pains  are  off,  the  uterus  will  be 
found  soft  and  yielding,  and  the  operation  may  be  effected  with  less 
danger ;  the  version  should  be  made  over  the  anterior  and  not  the  poste- 
rior surface  of  the  child,  holding  the  limb  or  limbs  firmly,  and  slowly 
and  gently  drawing  them  down  into  the  vagina,  and,  if  possible,  to 


PRETERNATURAL    LABOR — SHOULDER    PRESENTATIONS.         455 


the  external  orifice.  (Fig.  63.)  Should  the  uterus  contract,  the 
operator  must  cease  his  efforts,  and  if  the  pain  be  severe,  it  may  be 
necessary  for  him  to  straighten  out  the  pIG 

hand  and  let  the  foot  go,  recovering  it 
after  the  pain  has  subsided.  He  should 
place  his  unoccupied  hand  externally  on 
the  patient's  abdomen,  and  aid  in  ac- 
complishing the  version  by  pushing  the 
child's  breach  downward,  while  he  is 
making  traction  with  the  other  hand. 
As  the  arm  is  gradually  withdrawn,  the 
amniotic  fluid  will  gush  out  and  soil  the 
dress  of  the  operator,  if  he  has  not  pre- 
viously protected  it  by  a  covering. 

The  version  having  been  completed, 
the  patient  may  be  carefully  placed  in  bed,  leaving  the  rest  of  the 
labor  to  the  natural  efforts,  and  managing  it  as  directed  in  the  chapter 
devoted  to  breech  and  feet  presentations,  being  particular  to  have  the 
child's  face  in  the  hollow  of  the  sacrum  when  the  head  arrives  at  the 
lower  strait.  Some  obstetricians  recommend  to  terminate  the  delivery 
by  a  continuation  of  artificial  efforts,  gently  and  cautiously  extracting 
the  body  whenever  the  pains  are  on ;  but  I  consider  this  as  meddle- 
some and  unnecessary;  no  such  attempt  should  be  made,  unless 
circumstances  are  present  demanding  them.  After  the  delivery  of 
the  placenta,  the  female  should  be  properly  bandaged,  put  to  bed,  and 
a  soothing  preparation  administered,  if  her  condition  demands  it,  as. 
three  to  five  grains  of  the  compound  powder  of  Ipecacuanha  and 
Opium.  The  indications  for  Macrotys  and  Pulsatilla  may  be  man- 
ifest, and  for  several  days  their  administration  may  be  necessary. 
The  weakened  condition  produced  by  so  serious  an  operation  may 
demand  stimulation.  Meet  the  indications  promptly,  as  they  may 
develop,  being  governed  by  the  circumstances  surrounding  each  indi- 
vidual case.  She  should  also  be  kept  quiet  and  free  from  noise  and 
company,  and,  if  possible,  take  a  short  sleep.  Some  gruel  may  be 
allowed,  if  requested. 

The  operation  of  turning,  no  matter  how  skillfully  performed,  is. 
always  a  dangerous  one  for  the  mother,  and  should  be  performed  with 
the  greatest  care  and  gentleness;  any  hasty  or  careless  pushing,  any 
thrusting  of  the  knuckles  in  opposition  to  the  contracted  womb,  any 
attempts  at  version  during  a  pain,  may  occasion  laceration  of  the 


456  KING'S  ECLECTIC  OBSTETRICS. 

vagina,  rupture  of  the  uterus,  or,  perhaps,  both  of  these  may  occur. 
"If,  under  your  attempts  to  turn,  you  feel  any  fibers  giving  way, 
whether  in  the  womb  or  vagina,  withdraw  the  hand  immediately. "- 
(Blunddl.) 

Should  the  membranes  have  ruptured  before  the  attempt  at  version 
has  been  made,  and  which  is  more  frequently  the  case,  the  rules  just 
given  are  those  by  which  the  practitioner  must  be  guided;  and  the 
sooner  he  undertakes  the  operation  after  their  rupture,  the  os  uteri 
being  sufficiently  dilated,  and  dilatable,  the  greater  will  be  the  chances 
of  safety  for  the  mother  and  child,  and  the  easier  will  it  be  for  the 
successful  accomplishment  of  the  version. 

Unfortunately,  however,  preternatural  presentations  do  not  always 
present  the  same  features.  It  is  frequently  the  ease  that  the  mem- 
branes will  have  prematurely  ruptured,  and  the  os  uteri  will  not  be 
sufficiently  dilated;  or,  when  fully  dilated,  there  may  be  violent 
pains,  with  rigidity  and  irritation  of  the  parts.  In  these  instances  no 
attempts  whatever  must  be  made  to  force  the  hand  within  the  uterus, 
as  they  will  only  tend  to  increase  the  difficulty.  Dilatation  must  be 
aided  by  the  internal  use  of  Gelsemium,  in  the  frequently  repeated 
small  dose.  The  compound  tincture  of  Lobelia  and  Capsicum  will 
accomplish  the  same  purpose,  and  was  formerly  much  in  use;  at 
present  the  Sp.  Tr.  Lobelia  is  more  often  used  singly,  and  is  a  most 
excellent  agent  as  a  relaxant,  in  rigidity  of  the  os  uteri.  Vaginal 
emollient  injections  with  or  without  Laudanum,  according  to  the 
nature  of  the  case,  may  likewise  be  exhibited  in  some  instances. 
Fomentations  to  the  vulva,  of  Hops  and  Lobelia  combined,  have 
been  recommended  to  aid  in  the  relaxation  of  the  parts;  the  means 
already  suggested,  however,  will  usually  be  all  that  is  necessary. 
Chloroform  or  Ether,  inhaled  to  produce  anesthesia,  should  always 
be  used,  unless  positively  contra-indicated,  and  will  undoubtedly  be 
found  of  advantage,  by  removing  the  voluntary  efforts  of  the  mother, 
especially  the  actions  of  the  diaphragm  and  abdominal  muscles  —  and 
thus  enabling  the  operator  to  more  readily  effect  turning,  even  in 
cases  where,  without  anesthesia,  it  would  have  been  impossible  to 
accomplish  it  —  though  it  must  be  recollected  that  the  most  profound 
anaesthesia  does  not  completely  check  the  contractions  of  the  uterus. 
Bleeding,  ad  deliquum  animi,  is  the  practice  most  commonly  advised 
in  these  cases,  and  there  is  no  doubt  but  that  it  will  generally  produce 
the  desired  relaxation,  but  I  am  decidedly  opposed  to  it,  because  its 
aftereffects  upon  the  patient  are  frequently  irremediable;  it  induces  a 


PRETERNATURAL,    LABOR — SHOULDER    PRESENTATIONS.         457 

debility  of  the  nervous  and  vascular  systems,  which,  if  ever  positively 
recovered  from,  will  require  months  and  even  years  of  proper  treat- 
ment to  accomplish;  it  occasionally  fails  to  effect  the  desired  relax- 
ation; and  should  hemorrhage  or  other  symptoms  come  on  after  vene- 
section, there  may  not  remain  sufficient  energy  or  vitality  in  the 
system  to  successively  oppose  a  fatal  result.  On  the  other  hand,  the 
desired  relaxation  can  always  be  effected  by  the  use  of  Gelsemium, 
Lobelia,  or  the  combination  of  Lobelia  and  Capsicum,  by  which  all 
rigidity  will  be  overcome,  the  pulse  will  be  lessened,  abnormal  heat 
and  tenderness  of  the  parts  alleviated,  and  no  strength  of  the  patient 
actually  lost,  and  should  symptoms  occur  requiring  an  opposing  force 
of  the  system,  the  patient  may  readily  and  permanently  be  restored  to 
her  usual  vigor  by  the  employment  of  stimulants. 

No  haste  is  required  in  these  cases — viz.:  when  the  os  is  not 
dilated,  with  premature  rupture  of  the  membranes,  or,  when  it  is  fully 
dilated,  the  waters  having  been  discharged,  and  the  pains  violent — 
the  safety  of  the  mother  is  the  grand  object,  and  patience  is  required 
on  the  part  of  the  practitioner,  together  with  cool,  calm  and  deliberate 
action.  As  soon  as  the  parts  are  in  proper  condition,  the  hand  may 
be  introduced,  and  version  effected  as  before  explained.  In  these 
cases,  where  the  waters  have  been  discharged,  it  is  better  to  turn  by  a 
knee,  than  allow  the  hand  to  remain  too  long  within  the  uterus 
searching  for  a  foot.  When  the  pains  are  very  violent,  and  the  uterus 
contracts  firm-ly  about  the  body  of  the  child,  the  tincture  of  Gelsem- 
ium should  be  given,  combined  with  a  sufficient  quantity  of  Lauda- 
num, which  will  commonly  arrest  the  powerful  action  of  the  organ, 
and  at  the  same  time  produce  considerable  relaxation  of  it,  as  well  as 
of  the  soft  parts,  so  that  the  hand  can  be  introduced.  I  have  likewise 
found  Gelsemium,  combined- with  Aconite,  gtts  xx  to  gss  of  the  former 
and  gtts  v  to  x  of  the  latter  to  a  half-glass  of  water  and  administered 
in  half-teaspoonful  doses  every  half-hour  or  hour,  as  the  case  may 
require,  will  overcome  the  powerful  contractions  of  the  uterus,  lessen 
the  pains  materially,  and  render*  the  organ  more  yielding;  and  it  is 
more  especially  in  these  instances  where  a  resort  to  ansesthctics  is 
advised.  Of  course,  in  these  cases,  the  hazard  to  the  child  is  always 
much  greater.- 

Sometimes,  although,  the  foot  descends  into  the  vaginal  cavity,  yet 
the  shoulder,  being  wedged  in  the  pelvic  brim,  does  not  recede,  and 
the  more  forcible  the  traction  is  upon  the  foot,  the  more  firmly  does 
the  shoulder  become  fixed  in  the  brim,  while  the  breech  will  not  pass 


458  KING'S  ECLECTIC  OBSTETRICS. 

clown.  In  these  cases,  a  noose  of  strong  tape  or  ribbon  must  be  fixed 
round  the  ankle  of  the  foot  in  the  vagina,  upon  which  traction  may 
be  made  with  one  hand,  in  the  direction  of  the  pelvic  axis,  while  the 
other,  with  the  ends  of  the  fingers  placed  against  the  ribs  or  axilla," 
must  make  at  the  same  time  a  steady,  upward  pressure,  by  means  of 
which  the  shoulder  will  be  dislodged,  affording,  by  its  recession,  a 
space  for  the  descent  of  the  breech.  The  rest  of  the  delivery  is  then 
terminated  as  in  the  before  named  instances. 

In  cases  of  shoulder  presentation  where  the  arm  lias  descended,  it 
should  never  be  returned  within  the  uterine  cavity,  unless  in  attempt- 
ing cephalic  version,  as  referred  to  hereafter.  The  presence  of  the  arm 
assists  the  practitioner  in  forming  his  diagnosis  as  to  the  position,  etc., 
and  never  interferes  with  the  introduction  of  the  hand  for  the  opera- 
tion of  turning.  A  piece  of  ribbon  may,  however,  be  attached  to  the 
wrist,  for  the  purpose  of  preventing  the  arm  from  rising  along  side  of 
the  head  after  the  version  is  accomplished,  and  thus  avoiding  any 
difficulty  in  its  delivery.  Any  pulling  or  twisting  of  the  arm  is 
highly  censurable;  pulling  at  the  arm  will  not  assist  the  least  in  the 
delivery  of  the  child,  and  twisting  or  amputating  it  has  been  per- 
formed on  several  occasions,  in  which  the  children  were  subsequently 
born  alive,  and  some  of  whom  lived  to  advanced  age  in  this  mutilated 
condition.  Should  any  cause  be  present  demanding  the  removal  of 
the  prolapsed  arm,  it  should  always  be  made  known  to  the  relatives, 
together  with  the  reasons,  previous  to  any  attempt  at  the  mutila- 
tion. 

It  will  sometimes  be  the  case  that,  notwithstanding  our  treatment, 
the  contractions  of  the  uterus  will  continue  powerful  and  almost 
unremitting,  obstinately  resisting  the  slightest  attempts  to  introduce 
the  hand;  in  such  instances,  the  only  method  is  to  wait,  in  the  hope 
that  spontaneous  evolution  may  expel  the  fetus;  but  if  it  be  dead,  as 
known  by  auscultation,  or  if  symptoms  of  sinking  or  exhaustion  appear 
in  the  mother,  we  should  proceed  at  once  to  remove  the  child  by  ex- 
visceration.  In  thes-e  instanccSj  the  child  will  generally  be  dead 
before  interference  will  be  required,  and  the  grand  object  of  the  prac- 
titioner must  always  be  to  save  the  mother's  life,  if  possible.  In  many 
instances  Macrotys,  or  the  mixture  of  Gelsemium  and  Aconite  pre- 
viously referred  to,  will  be  found  very  successful  in  overcoming  this 
excitable  condition  of  the  uterus.  And  when  the  stomach  is  also 
irritable,  rejecting  almost  everything  exhibited,  minute  doses  of  mor- 
phia will  frequently  prove  useful. 


PRETERNATURAL    LABOR SHOULDER    PRESENTATIONS.  459 

X 

Dr.  Matteucci.  an  Italian  physician,  asserts  that  chloral  will  arrest, 
or  at  all  events,  sensibly  diminish  uterine  contractions,  and  may  there- 
fore be  advantageously  administered  in  cases  where  version  can  not 
be  accomplished  on  account  of  excessive  uterine  action;  from  five  to 
seven  grains  may  be  given,  and  this  dose  be  repeated  only  once  sub- 
sequently, at  an  interval  of  twelve  minutes  from  the  first;  if  the 
woman  can  not  retain  the  remedy  from  vomiting,  one  drachm  of 
chloral  added  to  three  fluidounces  of  water  may  be  injected  into  the 
rectum,  repeating  the  injection,  if  necessary,  in  half  an  hour. — Subcu- 
taneous injection  of  one-sixth  of  a  grain  of  morphia  in  the  region  of 
the  linea  alba,  and  midway  between  the  umbilicus  and  pubis,  has  been 
successfully  employed  by  Prof.  Braun,  of  Vienna,  to  overcome  the 
violent  spasmodic,  tetaniform  contractions  of  the  uterus.  The  child 
being  extracted  by  version,  without  pains. 

SPONTANEOUS  EVOLUTION,  is  an  idea,  which  was  advanced 
by  Denman,  in  1772,  who  noticed  that  the  labor,  in  shoulder  presen- 
ta^ions,  where  the  liquor  amnii  had  long  been  discharged,  occasionally 
terminated  by  the  natural  efforts,  the  breech  being  expelled  first,  and 
who,  consequently  supposed,  that  the  efforts  of  the  uterus  gradually 
turned  the  child  so  as  to  cause  the  shoulders  to  rise  as  the  breech 
descended.  In  1811,  Dr.  Douglas,  of  Dublin,  showed  that  this  view 
was  not  correct,  but  that  the  fetus  instead  of  being  turned  was  actually 
expelled  doubled  up.  His  description  of  the  occurrence,  which  he 
has  more  correctly  named  "  spontaneous  expulsion,"  is,  according  to 
Ramsbotham,  as  follows  :  "By  the  continuance  of  the  powerful  uterine 
contractions,  the  whole  of  the  arm  is  protruded  externally,  the  shoul 
der  and  chest  being  propelled  low  into  the  pelvic  cavity.  The 
acromion  then  appears  under  the  symphysis  pubis ;  and  as  the  loins 
and  breech  descend  into  the  pelvis  on  one  side,  the  apex  of  the- 
shoulder  is  directed  upward  toward  the  mons  veneris.  Further  room 
is  thus  gained  for  the  complete  reception  of  the  breech  into  the  cavity 
of  the  sacrum,  and  that  part  of  the  child's  body  is  eventually  expelled, 
sweeping  the  sacrum,  and  distending  the  perineum  to  a  vast  extent. 
As,  during  the  whole  of  this  process,  the  head  remains  above  the 
pelvic  brim,  it  is  evident  that  the  apex  of  the  shoulder  being  external, 
the  clavicle  must  be  strongly  pressed  against  the  under  surface  of  the 
symphysis  pubis;  on  which  point,  indeed,  the  fetal  body  partially 
revolves,  as  on  an  axis;  the  other  shoulder  and  arm,  and  the  head, 
being  expelled  last." 

Spontaneous  evolution,  or  spontaneous  expulsion,  seldom  happens, 
oeing  more  common  in  premature  labors,  and  is  always  fatal  to  the 


460  KIN(i's    KCLKCTK'    <>!>'!  KTUHS. 

child,  and  exceedingly  dangerous  to  the  mother;  the  intense  and  pro- 
tracted sufferings  which  the  mother  undergoes  are  beyond  description, 
and  no  practitioner  should  ever  trust  to  a  delivery  by  this  method, 
unless  under  the  circumstances  heretofore  named,  viz.:  where  every 
other  resource  fails.  Beside,  it  is  exceedingly  doubtful  whether  this 
spontaneous  action  will  ensue  at  all,  except  when  the  fetus  is  very 
small,  or  the  pelvis  much  larger  than  ordinary.  Dr.  Douglas  says; 
"  If  the  arm  of  the  fetus  should  be  almost  entirely  protruded,  with 
the  shoulder  pressing  on  the  perineum ;  if  a  considerable  portion  of 
its  thorax  be  in  the  hollow  of  the  sacrum,  with  the  axilla  low  in  the 
pelvis;  if,  with  this  disposition,  the  uterine  efforts  be  still  powerful, 
and  if  the  thorax  be  forced  sensibly  lower  during  the  pressure  of  each 
successive  pain,  the  evolution  may  with  great  confidence  be  expected." 
A  labor  in  which  spontaneous  evolution  is  effected,  requires  unpar- 
alleled voluntary  efforts  on  the  part  of  the  female,  and  is  always 
accompanied  with  extreme  bodily  and  mental  suffering,  frequently 
occasioning  death,  either  before,  or  soon  after  delivery;  and  should  the 
patient  survive,  she  is  commonly  left  with  some  incurable  difficulty, 
which  renders  life  anything  but  desirable.  Velpeau  states  that,  in 
one  hundred  and  thirty-seven  labors  of  this  description,  only  twelve 
children  were  born  alive.  When  the  fetus  has  fairly  engaged  in  the 
pelvic  brim,  spontaneous  expulsion  only  can  occur ;  when  it  remains 
free  above  the  brim,  spontaneous  evolution,  to  a  certain  extent,  may 
take  place. 

EXVISCERATION,  should  be  resorted  to  only  as  a  last  resource, 
and  should  be  employed  in  those  cases  where  the  membranes  have 
been  ruptured  for  several  hours,  with  no  advance  of  the  labor,  and 
also  in  instances  where  the  child's  body  is  firmly  wedged  at  some  part 
of  the  pelvis,  rendering  the  introduction  of  the  hand  impossible  or 
extremely  dangerous.  In  performing  this  operation  there  is  no  neces- 
sity for  amputating  the  arm,  but  an  assistant  will  make  traction  upon 
it,  for  the  purpose  of  bringing  as  much  of  the  child's  thorax  into  the 
pelvis  as  possible ;  the  operator  will  then  pass  two  fingers  of  the  left 
hand  upward  within  the  vagina,  until  he  feels  one  of  the  intercostal 
spaces,  selecting  a  point  as  near  the  axilla  as  he  can ;  the  perforator  is 
then  to  be  passed  along  these  two  fingers,  and  a  free  opening  made 
with  it  in  the  selected  intercostal  space.  As  it  will  be  necessary  to 
introduce  the  hand  within  this  opening,  and  into  the  cavity  of  the 
fetal  thorax,  for  the  purpose  of  removing  its  contents,  the  operator 
may  divide  one  or  more  ribs,  so  that  the  opening  will  be  sufficiently 


PRETERNATURAL    LA15OU SHOULDER    PRESENTATIONS.  461 

large.  After  the  removal  of  the  thoracic  contents,  the  diaphragm 
may  be  perforated,  and  the  liver  and  intestines  extracted.  The 
removal  of  these  organs  will  occasion  a  collapse  of  the  body,  which 
will  be  expelled  doubled  up,  if  the  uterine  contractions  are  sufficiently 
energetic,  without  any  further  interference :  but  if  the  pains  are  weak 
and  inefficient,  or  have  entirely  ceased,  the  delivery  must  be  artificially 
accomplished  by  the  crotchet,  removing  rib  after  rib,  hips,  buttocks, 
etc.;  or  the  instrument  may  be  "carried  through  the  opening  and  fixed 
within  the  fetal  ilium ;  the  breech  will  soon  be  observed  to  descend, 
and  the  case  will  be  terminated  as  though  nature  had  expelled  the 
child  unaided." 

Ramsbotham  refers  to  an  operation  for  decapitating  the  child,  in 
transverse  presentations,  when  turning  is  impracticable,  and  when  the 
neck  is  directly  over  the  brim :  fortunately,  I  have  never  had  occasion 
to  resort  to  it.  He  recommends  the  finger  to  be  passed  around  the 
neck,  a  large-sized  blunt  hook  to  be  introduced  upon  it,  and  the 
presenting  part  to  be  then  brought  as  low  into  the  pelvis  as  is  con- 
sistent with  the  woman's  safety.  The  hook  must  then  be  steadied  by 
an  assistant,  while  the  operator  introduces  the  decapitator  (a  hook  with 
an  internal  cutting  edge)  by  the  side  of  the  blunt  hook :  this  latter  is 
then  removed,  and  the  finger  of  the  left  hand  being  kept  constantly  in 
contact  with  the  blunt  point  of  the  cutting  hook,  a  sawing  motion  is 
communicated  to  it  by  means  of  the  right  hand,  and  the  separation  is 
thus  effected ;  after  which  the  child's  body  may  be  drawn  out  by  the 
protruding  arm,  and  the  head  removed  by  a  crotchet  or  blunt  hook, 
introduced  into  the  mouth  or  the  foramen  magnum.  These  operations, 
of  course,  are  only  to  be  performed  when  the  child  is  dead,  and  which 
will  almost  always  be  the  case  before  a  resort  to  them  will  be  sanctioned 
by  a  skillful  accoucheur. 

In  cases  of  shoulder  presentation,  CEPHALIC  VERSION  has 
occasionally  been  attempted,  in  which  the  presenting  part  has  been 
pushed  away  and  the  head  brought  to  the  brim ;  but  the  operation  has 
not  received  the  sanction  of  many  obstetricians,  on  account  of  the 
difficulties  attending  it.  Professor  Meigs,  in  his  work  on  Obstetrics, 
remarks:  "It  may  be  that  those  old  practitioners  of  the  days  of  Queen 
Elizabeth  may  have  sometimes  succeeded,  by  pushing  up  the  present- 
ing shoulder,  in  getting  the  head  at  last:  to  come  to  the  strait  again, 
Out  such  an  event  appears  to  me  in  any  case  most  improbable." 
Professor  Miller  observes:  "  Cephalic  version  has  but  few  advocates 
at  the  present  day,  and  is  confessedly  applicable  to  such  a  limited 


462  KING'S  ECLECTIC  OBSTETRICS. 

number  of  cases,  that  it  is  scarcely  worthy  of  our  formal  considera- 
tion." 

It.will  thus  be  seen  that  authors  generally  agree  in  considering 
cephalic  version,  at  best,  a  doubtful  expedient,  and  one  to  be  attempted 
only  as  a  dernier  resort  in  some  particular  instances;  yet,  notwith- 
standing the  observations  of  the  above  gentlemen  concerning  this  oper- 
ation, and  the  disrepute  in  which  it  is  held,  Dr.  M.  B.  Wright,  a  former 
talented  and  skillful  physician  of  Cincinnati,  and  Professor  of  Obstet- 
rics in  the  Ohio  Medical  College,  has  made  known  a  method  of  cephalic 
version,  which,  I  think,  will  become  the  more  general  practice  in  the 
management  of  shoulder  presentations  as  it  becomes  better  known: 
since  having  perused  his  essay,  I  have  tried  his  method  in  several  cases, 
and  was  highly  pleased  at  the  successful  results.  Dr.  Wright's  essay 
was  on  "Difficult  Labors  and  their  Treatment,"  and  was  read  before 
the  Ohio  State  Medical  Society  at  one  of  their  meetings,  who  awarded 
a  gold  medal  to  him.  In  order  that  my  readers  may  understand  his 
•views,  I  will  give  his  own  language  and  quote  freely  from  his  essay 
After  describing  several  cases  treated  successfully,  he  remarks: — 

"Now  after  all  this,  are  we  not  justified  in  declaring: 

"1.  That  at  an  early  period  in  labor,  and  especially  if  called  before 
the  uterus  has  been  deprived  of  its  liquid  contents,  a  shoulder  may  be 
converted  into  a  vertex  presentation  more  easily  than  turning  by  the 
feet  is  ordinarily  performed. 

"  2.  That  although  the  membranes  may  have  been  long  ruptured, 
turning  by  the  head  can  be  accomplished  with  great  facility. 

"  3.  That  delivery  by  cephalic  version  may  be  speedily  effected,  after 
repeated  and  ineffectual  efforts  have  been  made  to  turn  by  the  feet. 

"  4.  That  cephalic  version  should  receive  a  prominent,  nay,  leading 
place,  as  a  means  of  expediting  delivery  in  shoulder  presentations. 

"  The  second  of  the  questions  already  proposed  is,  what  mode  of 
proceeding  will  prove  most  favorable  for  the  mother  ? 

"In  his  chapter  on  Podalic  Version,  Churchill  -  observes  :  'On  the 
other  hand,  its  disadvantages  are  not  to  be  overlooked.  From  the 
distance  the  head  has  to  traverse,  and  the  difficulty  of  seizing  the  feet, 
and  of  turning  the  child  in  utero,  there  must  ever  be  a  fearful  risk  of 
injury  to  the  mother.' 

"  Upon  an  examination  of  the  tabular  views  given  by  Lee,  we  find 
that  out  of  seventy-one  cases  of  shoulder  presentations,  in  which 
turning  by  the  feet  was  resorted  to,  f  seven  women  died  from  rupture, 
and  three  from  inflammation  of  the  uterus !'  Laceration  and  inflam- 
mation of  the  uterus  are,  therefore,  the  consequences  chiefly  to  be 


PRETERNATURAL  LABOR— SHOULDER  PRESENTATIONS.     463 

dreaded.  Four  of  these  cases  of  rupture  occurred  in  the  practice  of 
other  accoucheurs,  and  three  in  patients  under  my  own  care,  and 
where  no  great  difficulty  was  experienced  or  force  employed  in 
turning.' 

"  In  cephalic,  version  the  hand  does  not  enter  the  cavity  of  the  uterus, 
and,  consequently,  neither  its  walls,  nor  any  portion  of  them,  are 
forcibly  pushed  out.  The  fetus  is  moved  comparatively  little  within 
the  uterus,  the  head  being  already  near  the  superior  strait ;  while  in 
podalic  version  the  part  to  be  first  delivered  is  most  remote  from  the 
canal  through  which  it  must  pass.  In  the  former,  the  injury  to  the 
mother  can  not  result  without  great  awkwardness  on  the  part  of  the 
obstetrician,  while  in  the  other  we  have  reason  to  feel  surprised  at  the 
escape  from  injury.  In  turning  by  the  feet,  the  hand  must  necessarily 
be  moved  considerably  within  the  uterus,  and  often  while  it  is  con- 
tracting violently.  In  turning  by  the  head  there  is  but  little,  if  any, 
direct  contact  of  the  hand  within  the  uterus.  In  the  one  case,  con- 
tusion of  the  uterus  by  the  hand  is  to  be  expected  ;  in  the  other  case 
there  is  no  injury,  because  there  is  no  contact.  Turning  by  the  feet 
may  occasion  a  severe  nervous  shock :  not  so  in  changing  the  shoulder 
for  the  head. 

"  How  may  the  life  of  a  child  be  best  preserved?  is  the  third  inquiry 
to  be  briefly  answered. 

"  In  describing  the  disadvantages  of  turning  by  the  feet  in  all  cases, 
Churchill  says  :  '  The  mortality  among  the  infants  thus  brought  into  the 
world  is  very  great.  As  far  as  our  statistics  extend  they  yield  174  out 
of  518  delivered,  or  one  in  three.' 

"  The  mortality  in  shoulder  presentations  is,  doubtless,  greater  than 
this.  In  the  first  place  the  position  of  the  fetus  weakens  its  hold  upon 
life.  In  the  second  place  the  hand  is  more  difficult  of  introduction 
into  the  uterus  in  shoulder  than  in  head  presentations,  and  whatever 
force  is  required  is  sensibly  felt  by  the  fetus,  and  upon  that  part  of 
the  body  where  pressure  is  made  with  the  least  impunity. 

"  A  timely  resort  to  cephalic  version  gives  to  the  fetus  almost  as 
much  certainty  of  life  as  if  the  presentation  had  been  originally  of 
the  head.  "Why  not?  The  manoeuver  amounts  to  but  little  more  than 
in  rectification  of  deviated  head  positions. 

"  We  are  informed  by  Churchill,  that  '  Bush  gave  an  account,  in 
1826,  of  fifteen  cases,  in  which  fourteen  were  born  living.  In  1827, 
Kitgen  collected  forty-five  successful  cases.  Eiecke  has  had  sixteen 
cases.'  In  all  the  cases  treated  by  myself  from  the  beginning,  the 
children  were  born  alive.  The  liability  to  compression  of  the  cord 


464  KING'S  ECLECTIC-  OBSTETRICS. 

and  consequent  death  of  the  fetus,  is  in  proportion  to  the  length 
of  the  labor,  or  rather  to  the  descent  of  the  fetus  in  the  cavity  of  the 
pelvis.  Hence,  to  be  wholly  successful,  cephalic  version  should  be 
performed  a  short  time  before,  or  soon  after  the  commencement  of  the 
second  stage  of  labor. 

"  Can  any  one  mode  of  treating  shoulder  presentations  be  relied  on 
exclusively  ?  The  answer  must  be  in  the  negative.  We  are  disposed 
to  adopt  the  language  of  Cazeaux,  "  that  at  the  present  day  it  would 
be  improper  to  embrace  either  opinion  exclusively,  for  some  cases  are 
better  suited  to  the  cephalic  version,  while  there  are  others  on  the 
contrary,  where  the  pelvic  one  is  alone  practicable ;  consequently,  both 
operations  should  be  retained  in  practice,  leaving  the  judgment  of  the 
accoucheur  to  determine  the  cases,  where  the  one  or  the  other  ought  to 
be  preferred.'  And  we  will  conclude  this  part  of  the  subject  by 
stating  a  few  of  the  circumstances  under  which  the  different  modes  of 
turning  may  be  adopted. 

"  Turning  by  the  feet  is  to  be  preferred  in  cases  of  inefficient  uterine 
action,  or  in  exhaustion  from  long  continuance  of  labor;  in  hemor- 
rhage, convulsions,  or  in  any  case  in  which  there  may  be  a  demand 
for  speedy  delivery. 

"  Turning  by  the  head  should  be  selected  in  all  cases  where  difficulty 
arises  from  mal-position  merely ;  or  in  convulsions,  hemorrhage,  or 
prolapsus  of  the  funis,  if  the  uterus  should  be  engaged  in  vigorous 
expulsive  efforts.  In  rupture  of  the  uterus  our  great  reliance  is  in 
artificial  delivery ;  and  the  question  naturally  suggested  would  be, 
which  will  guarantee  the  greatest  safety,  podalic  version,  or  cephalic 
version  aided  by  the  forceps  ?  And  we  would  be  guided  in  our  action 
by  the  answer  we  gave  to  the  question. 

"THE  HAND  TO  BE  USED.— The  relations  of  the  fetus  to  the 
pelvis  having  been  ascertained,  and  the  patient  placed  in  a  proper 
position  for  the  version,  the  next  question  is,  which  hand  shall  be 
introduced  into  the  vagina?  We  answer,  the  hand,  the  palm  of  which 
is  directed  naturally  toward  the  breech  of  the  fetus.  It  will  be  seen 
at  once,  that  if  the  fetus  is  to  be  moved  in  the  direction  of  the  breech, 
and  in  correspondence  with  the  right  side  of  the  mother,  and  the  left 
side  of  the  operator,  the  right  hand  could  be  used  with  most  success. 
In  cases  in  which  the  head  occupies  the  right  iliac  fossa,  a  choice  could 
be  given  to  the  left  hand. 

"  THE  PROLAPSED  ARM.— It  is  generally  conceded,  that  in 
turning  by  the  feet,  it  is  not  necessary,  nor  would  it  be  advantageous, 


PRETERNATURAL    LABOR — SHOULDER    PRESENTATIONS.         465 

to  return  above  the  brim  of  the  pelvis,  the-arm  which  may  have  fallen, 
or  been  brought  into  the  vagina.  In  turning  by  the  head,  on  the  con- 
trary, its  reposition  admits  of  no  doubt ;  it  is  imperatively  demanded. 
It  is  not  demanded  in  consequence  of  any  difficulty  in  moving  the 
shoulder  by  its  presence,  but  in  the  adjustment  of  the  head  at  the 
superior  strait,  and  its  subsequent  descent  through  the  pelvis.  By 
bending  the  fore-arm  of  the  fetus  until  the  hand  is  directed  to  the 
upper  portion  of  the  vagina,  and  then  pushing  up  the  arm,  the  entire 
member  will  soon  ascend  above  the  brim  of  the  pelvis,  and  be  no 
longer  an  obstacle  to  complete  version. 

"  The  uterus  undergoing  gradual  distension  by  the  growth  of  the 
fetus,  and  by  increase  in  the  quantity  of  liquor  amnii,  is  not  from 
this  cause  alone  excited  to  an  expulsion  of  its  contents.  Let  a  strong 
and  sudden  mechanical  force  be  applied  to  the  fibers  of  the  uterus, 
even  to  a  limited  extent,  and  contraction  will  speedily  follow.  If  any 
portion  of  the  fetus  should  be  pushed  forcibly  against  the  fundus  of 
the  uterus,  by  atteknpts  to  rectify  a  Dial-presentation,  a  more  than 
corresponding  resistance  would  soon  apprise  us  of  a  want  of  adroitness, 
and  the  probabilities  of  failure.  The  hand  of  the  manipulator  in  the 
vagina  imparts  a  sense  of  fullness,  and  induces  expulsive  efforts  on  the 
part  of  the  mother.  Pressure  on  the  internal  face  of  the  perineum, 
or  along  the  recto-vaginal  septum,  urges  the  uterus  to  renewed  or  more 
energetic  action.  Simple  contact  of  the  uterine  and  fetal  surfaces  in 
turning  does  not  produce  undue  contraction  of  the  uterine  walls.  The 
presence  of  the  hand,  added  to  that  of  the  fetus,  within  the  uterus,  is  a 
common  cause  of  irritation  and  expulsive  force.  But  the  fact,  which 
we  most  desire  to  enforce  here,  is,  that  when  the  fetus,  in  the  operation 
of  turning,  is  moved  in  straight  lines,  and  sensibly  displaces  the  uterine 
fibers  with  which  it  comes  in  contact,  it  is  speedily  forced  back  to  its 
original  mal-position ;  nor  can  its  displacement  be  easily  rectified, 
except  it  be  moved  in  conformity  to  the  curvatures  of  the  cavity  in 
which  it  is  contained. 

"THE  MANNER  OF  PEE  FORMING  CEPHALIC  VER- 
SION.— Suppose  the  patient  to  have  been  placed  upon  her  back,  across 
the  bed,  with  her  hips  near  its  edge — the  presentation  to  be  the  right 
shoulder,  with  the  head  in  the  left  iliac  fossa — the  right  hand  to  have 
been  introduced  into  the  vagina,  and  the  arm,  if  prolapsed,  having 
been  placed,  as  near  as  may  be,  in  its  original  position  across  the  breast. 
We  now  apply  our  fingers  upon  the  top  of  the  shoulder,  and  our  thumb 
in  the  opposite  axilla,  or  on  such  part  as  will  give  us  command  of  the 
chest,  and  enable  us  to  apply  a  degree  of  lateral  force.  Our  left  hand 
30 


46«>  KING'S  KCLI-XTIC  OBSTETRICS. 

is  also  applied  to  the  abdonlen  of  the  patient,  over  the  breech  of  the 
fetus.  Lateral  pressure  is  made  upon  the  shoulders  in  such  a  way  as 
to  give  to  the  body  of  the  fetus  a  curvilinear  movement.  At  the  same 
time  the  left  hand,  applied  as  above,  makes  pressure  so  as  to  dislodge 
the  breech,  as  it  were,  and  move  it  toward  the  center  of  the  uterine 
cavity.  The  body  is  thus  made  to  assume  its  original  bent  position, 
the  points  of  contact  with  the  uterus  are  loosened,  and  perhaps  dimin- 
ished, and  the  force  of  adhesion  is  in  a  good  degree  overcome.  Without 
any  direct  action  upon  the  head  it  gradually  approaches  the  superior 
strait,  falls  into  the  opening,  and  will,  in  all  probability,  adjust  itself 
as  a  favorable  vertex  presentation.  If  not,  the  head  may  be  acted 
upon  as  in  deviated  positions  of  the  vertex,  or  it  may  be  grasped, 
brought  into  the  strait,  and  placed  in  correspondence  with  one  of  the 
oblique  diameters. 

"  It  will  be  observed  that  we  do  not  act  upon  the  shoulders  by  raising 
them.  Perhaps  a  slight  elevation  would  facilitate  the  movement 
already  described — or  it  might  be  better  to  depress  them — and  again, 
by  lateral  pressure,  without  either  elevation  or  depression,  our  object 
might  be  accomplished.  Pushing  up  the  shoulders,  therefore,  does  not 
constitute  a  prominent  part  of  turning,  if  by  pushing  up  is  meant  the 
mere  raising  of  the  shoulders  above  the  brim  of  the  pelvis. 

"As  the  body  of  the  fetus  makes  its  curved  movement  under  the 
hand  of  the  operator,  it  advances  upward,  as  well  as  laterally,  by  a 
combined,  rather  than  a  single  action,  which  would  give  it  only  one 
direction. 

"  The  back  of  the  hand,  with  which  we  have  been  acting  upon  the 
shoulder,  is  toward  the  head  of  the  fetus — consequently,  its  hold  upon 
the  head  would  be  apparently  slight — yet,  after  the  shoulders  have 
reached  the  iliac  fossa,  the  vertex  may  fall  upon  the  palm  of  the  hand 
in  occupying  the  strait,  and  its  adjustment  become  easy.  If,  however, 
there  should  seem  to  be  a  necessity  for  grasping  the  occiput,  there 
could  be  no  reasonable  objection  to  a  speedy  change  of  haripls. 

"  The  entire  process  of  cephalic  version  is  to  be  adopted  in  the 
absence  of  uterine  contraction ;  or,  rather,  during  the  intervals  of 
expulsive  force.  And,  as  it  is  now  a  vertex  presentation,  we  must  be 
governed,  as  to  the  time  and  manner  of  delivery,  by  those  general 
rules  applicable  to  such  cases. 

"In  all  our  cases,  except  the  one  which  terminated  as  a  face  pre- 
sentation, the  occiput  assumed  a  position  corresponding  with  the  first 
or  second  position  of  the  vertex.  In  this  case  the  occiput  was  before 


PRETERNATURAL  LABOR SHOULDER  PRESENTATIONS.    467 

••one  of  the  saero-iliac  symphyses,  and  to  this  fact  we  have  attributed 
the  tendency  of  the  occiput  to  slide  above  the  brim  of  the  pelvis,  and 
the  difficulty  in  keeping  it  in  place.  If  there  had  been  the  usual 
degree  of  uterine  contraction,  however,  the  head  would,  in  all  proba- 
bility, have  become  fixed,  and  the  presentation  would  have  continued 
as  one  of  the  vertex,  instead  of  changing  for  the  face. 

"It  will  be  seen  that  we  lay  no  claim  to  the  introduction  of  cephalic 
version  as  a  mode  of  treating  wrong  presentations,  and  expediting 
delivery.  A  very  brief  examination  of  the  subject,  however,  may 
induce  some  to  award  to  us  originality  in  respect  to  the  means  by 
which  a  successful  change  of  presentation  may  be  accomplished. 

"  That  cephalic  version,  by  external  manipulation — by  acting  upon 
the  fetus  through  the  parieties  of  the  abdomen  and  uterus — should 
have  few  advocates,  is  not  surprising.  To  be  successful,  it  confessedly 
requires  a  combination  of  favorable  circumstances  not  often  presented. 
The  tissues  both  of  the  abdomen  and  uterus  must  be  thin  and 
yielding — the  liquor  amnii  must  have  been  retained,  and  in  consider- 
able quantity — and  the  fetus  must  be  proportionally  small. 

"  In  all  the  obstetrical  works  we  have  examined,  in  which  cephalic 
version  is  recommended  by  internal  manceuver,  it  is  directed  to  raise 
the  shoulder  as  the  first  necessary  impression  upon  the  fetus.  Viewed 
anatomically  or  mechanically,  men  have  not  been  persuaded  into  the 
belief,  that  raising  the  shoulder  can  facilitate  the  permanent  descent 
of  the  head  into  the  superior  strait.  They  claim,  what  is  apparent  to 
the  eye  in  viewing  a  proper  engraving,  and  as  it  can  be  demonstrated 
with  the  manikin,  that  the  elevation  of  the  shoulder  at  the  brim  of 
the  pelvis,  tends  to  increase  the  long  diameter  of  the  fetus,  and  the 
transverse  diameter  of  the  uterus,  and  without  any  favorable  adjust- 
ment of  the  head  after  pressure  upon  the  shoulder  has  been  withdrawn. 

"Suppose  we  follow  out  the  directions  given  by  some,  and  after 
the  elevation  of  the  shoulder,  attempt  to  force  .the  body  of  the  fetus 
iji  a  lateral  direction,  will  not  the  breech  impinge  against  the  walls 
of  the  uterus  transversely?  To  enable  the  head  to  engage  in  the 
superior  strait,  the  body  must  be  entirely  removed  from  it,  and  this 
can  only  be  done  by  raising  the  breech  toward  the  fundus  of  the 
uterus.  Kaising  the  shoulder,  therefore,  is  very  naturally  considered 
a  means  to  prevent  cephalic  version.  And  we  are  not  surprised  that 
podalic  version  is  almost  universally  adopted  in  the  treatment  of 
shoulder  presentations. 

"  If  our  mode  of  performing  cephalic  version  is  sufficiently  clear,  in 
the  description  already  given,  it  will  readily  be  distinguished  from 


468  KING'S    ECLECTIC    OBSTETRICS. 

others.  We  claim  for  it  great  importance,  on  the  ground  that  it  is- 
easily  executed — that  the  mother  and  fetus  receive*  no  injury — that 
there  is  little  or  no  danger  of  subsequent  displacement  after  the  vertex 
has  been  fully  adjusted — that,  although  it  is  most  successful  in  recent 
cases,  delivery  may  be  accomplished  after  the  membranes  have  been 
long  ruptured — that  it  may  be  executed,  after  ineffectual  efforts  to 
bring  down  the  feet." 

I  commend  these  views  of  Dr.  Wright,  together  with  his  mode 
of  performing  cephalic  version,  to  the  special  attention  of  the  profes- 
sion, and  more  especially,  as  in  shoulder  presentations,  his  operation 
is  much  more  easily  and  promptly  performed  than  the  "combined 
external  and  internal  version  "  of  Dr.  Braxton  Hicks. 


CHAPTER    XXXV. 

ON    PRETERNATURAL    LABOR — TRANSVERSE     PRESENTATIONS — PRO- 
LAPSUS    OF     THE     UMBILICAL    CORD PLURALITY 

OF    CHILDREN MONSTERS. 

THE  transverse  presentations  which  follow,  are  rarely  met  with, 
and  some  obstetricians  have  expressed  doubts  as  to  the  possibility  of 
their  occurrence.  However,  as  they  are  treated  of  by  several  writers, 
I  have  deemed  it  proper  to  make  a  brief  reference  to  them.  ' 

Should  the  Side  of  the  child  present,  it  may  be  distinguished  from 
the  head  by  its  want  of  firmness  and  roundness,  as  well  as  by  the 
absence  of  sutures  and  fontanelles ;  from  the  breech,  by  the  want  of 
the  furrow  between  the  two  rotund  nates,  with  no  coccyx,  anus,  or 
genital  organs.  The  principal  discriminating  signs  of  a  side  presenta- 
tion are  the  presence  of  two  or  three  ribs,  with  the  intercostal  spaces; 
and  should  any  doubt  exist,  the  hand  should  be  passed  into  the 
vagina  sufficiently  to  allow  two  fingers  to  be  carried  fully  up  to  the 
superior  strait.  A  single  intercostal  space  may  be  mistaken  for  the 
sagittal  suture. 

If  the  child's  Back  presents,  three  or  four  of  the  spines  of  the 
vertebra  can  be  detected,  and  also  the  origins  of 'the  ribs;  and  these 
may  be  felt  even  previous  to  the  full  dilatation  of  the  os  uteri. 

A  Sternum  presentation  may  be  known  by  the  introduction  of  two 
fingers,  which  will  distinguish  the  sternal  bones,  the  continuance  of 
the  bony  plane,  the  cartilages  of  the  ribs  at  their  origin  from  the 
eternum,  and  the  intercostal  spaces. 


PRETERNATURAL  LABOR — TRANSVERSE  PRESENTATIONS,  ETC.  469 

When  the  Abdomen  presents,  there  will  be  felt  no  osseous  promi- 
nence, but  only  the  large,  soft  abdomen,  and,  perhaps,  the  ensiform 
cartilage  maybe  distinguished,  as  well  as  the  insertion  of  the  umbilical 
cord ;  though  the  practitioner  must  recollect  that  the  cord  itself  may 
present  when  the  abdomen  does  not,  as  in  prolapsus  of  the  cord. 

It  is  recommended  in  all  these  transverse  positions  to  effect  the 
delivery  by  turning,  the  practitioner  being  governed  in  the  operation 
by  the  rules  given  under  the  management  of  Shoulder  Presentations. 

A  PROLAPSUS  OF  THE  CORD,  is  where  the  umbilical  cord 
presents  along  with  the  head,  nates,  or  extremities  of  the  child,  and 
may  be  considered  under  the  head  of  Preternatural  Labor.  It  is  not 
frequently  met  with,  having  occurred,  according  to  statistics,  437  times 
in  105,146  cases,  or  about  1  in  240.  Of  itself,  the  falling  of  the  cord 
has  no  influence  upon  the  advance  of  labor,  its  smallness  of  size  and 
compressibility  offering  but  little  or  no  hinderance  to  the  passage 
of  any  part  of  the  child  through  the  pelvic  canal.  The  danger  is 
to  the  child,  which,  from  pressure  upon  the  umbilical  vessels,  may  die 
by  asphyxia.  Until  the  fetus  is  expelled  into  the  world,  its  life 
depends  upon,  and  is  sustained  by,  a  free  circulation  through  the 
arteries  and  vein  of  the  cord,  and  any  suspension  of  this  circulation, 
by  compression  or  otherwise,  will  necessarily  occasion  death,  by  inter- 
rupting the  communication  between  the  child  and  its  mother.  We 
may  form  some  idea  of  the  peril  to  which  the  child  is  exposed  from 
the  statistics  of  various  authors,  in  which  245  children  were  lost  out 
of  392  cases  of  prolapse,  being  considerably  more  than  one-half. 

Various  circumstances  have  been  referred  to  as  favoring,  or  causing 
a  descent  of  the  cord  ;  as  mal-positions  of  the  child  ;  an  uncommon 
length  of  the  cord;  uterine  obliquity  ;  and  malformation  of  the  pelvis, 
especially  the  contracted  pelvis.  A  small  child,  with  an  excessive 
amount  of  liquor  aninii,  may  contribute  to  the  descent  of  a  loop  of  the 
cord,  by  allowing  the  fetal  head  to  move  away  from  the  pelvic  brim. 
When  there  is  a  copiousness  of  the  amniotic  fluid,  the  sudden  rupture 
of  the  membranes  being  followed  by  a  forcible  gush  of  this  fluid,  may 
carry  with  it  a  loop  of  the  cord  ;  and  this  would  be  more  likely  to 
occur  should  the  patient  be  standing,  or  in  some  other  unfavorable 
attitude  when  the  rupture  happens.  Prolapse  of  the  cord  may  also 
arise  from  a  want  of  energetic  contractions  of  the  uterus,  in  which  the 
fetal  head  is  not  maintained  with  sufficient  power  at  the  superior  strait, 
.nor  closely  enough  adapted  to  the  inferior  segment  of  the  uterus. 
The  attachment  of  the  placenta  near  the  os  uteri,  by  which  the  cord 


470  KIKCK8    K(  LKCTK'    OH.STE Tl;K>. 

is  held  just  at  the  orifice  of  the  uterus,  likewise  favors  a  prolapsus. 
Cases  have  occurred  which  were  not  due  to  any  of  the  above-named 
causes,  and  which  could  not  be  satisfactorily  accounted  for.  Consid- 
ering the  length  of  the  cord,  and  facility  with  which  it  moves  about  in 
the  liquor  amnii,  it  is  somewhat  surprising  that  prolapsions  of  it  are 
not  more  frequently  met  with.  Vertex  presentations  are  less  fre- 
quently complicated  by  prolapse  of  the  funis,  than  footling,  in  which 
it  is  often  encountered.  It  is  more  dangerous  in  vertex,  less  so  in 
shoulder,  and  least  of  all  in  feet  presentations. 

DIAGNOSIS. — Prior  to  the  rupture  of  the  membranes,  it  is  very 
difficult,  if  not  entirely  impossible,  to  detect  the  cord ;  it  is  only  after 
the  rupture  that  we  can  determine  its  prolapse  with  any  degree  of 
certainty.  The  cord  then  hangs  down  in  the  vagina,  is  of  more  or 
less  length,  sometimes  passing  down  beyond  the  vulva ;  its  roundness, 
smoothness,  and  softness  may  enable  the  practitioner  to  distinguish  it 
when  in  the  vagina,  and  especially  its  pulsations,  if  the  circulation  has 
not  been  suspended,  and  which  are  not  synchronous  with  the  pulse  of 
the  mother ;  when  it  appears  externally,  it  can  be  readily  recognized. 
Care  should  be  taken  not  to  mistake  a  prolapsed  intestine  for  a  loop 
of  funis ;  this  has  been  done,  the  coil  of  intestine  passing  through  a 
rent  at  the  superior  part  of  the  vagina,  or  through  a  ruptured  uterus, — 
and  which,  in  several  instances  was  cut  in  two,  under  the  erroneous 
supposition  that  it  was  the  cord. 

TREATMENT. — In  the  management  of  cases  of  this  character, 
various  modes  of  treatment  have  been  advised,  but  none  of  them  have 
been  generally  successful.  If  the  cord  be  cold  and  flaccid,  with  no 
pulsations,  the  child  will  undoubtedly  be  dead,  and  as  assistance  is 
required  only  for  the  safety  of  the  child,  the  labor  should  be  allowed 
to  progress  without  any  interference,  unless  called  for  by  other  cir- 
cumstances. We  must,  however,  be  cautious  in  pronouncing  the 
child's  death,  for  the  pulsations  may  cease  during  the  contractions  of 
the  uterus,  and  return  again  as  soon  as  these  have  subsided ;  beside, 
instances  have  occurred  where  the  pulsations  have  not  been  recog- 
nized for  ten  or  fifteen  minutes,  and  yet  the  child  has  lived.  If  the 
membranes  have  not  ruptured,  when  the  prolapse  is  detected,  care 
should  be  had  to  preserve  them  entire  until  full  dilatation  of  the  os- 
uteri,  and  thus  prevent  any  dangerous  pressure  upon  the  cord,  until 
the  chances  are  greater  for  affording  relief. 

The  several  means  recommended  by  authors,  in  cases  where  the 
child  is  known  to  be  alive,  are  as  follows : 

1.  Returning  the  prolapsed  cord  above  the  superior  strait  and  the 
presenting  part  of  the  child,  and  retaining  it  there  until  this  has  so- 


PRETERNATURAL  LABOR — TRANSVERSE   PRESENTATIONS,  ETC.    471 

far  descended  that  any  further  prolapse  will  be  prevented.  If  this 
could  always  be  accomplished,  it  would  be  a  very  certain  and  desirable 
method ;  but,  usually,  the  difficulty  is  not  detected  until  after  the 
membranes  have  ruptured,  and  the  head  together  with  the  cord  have 
been  forced  down  into  the  brim;  and  then  any  such  attempts  would 
not  only  prove  unsuccessful,  but,  if  persisted  in,  might  still  further 
increase  the  difficulty  by  displacing  the  head.  Not  unfrequently  the 
os  uteri  may  be  incompletely  dilated,  and  then  any  attempts' to  return 
the  cord  would  be  impracticable.  When  it  is  fully  dilated,  the  attempt 
to  ejevate  the  presenting  part,  or  to  carry  the  fingers  with  the  cord 
between  the  os  uteri  and  the  presenting  part  might  occasion  a  return 
of  the  pains,  and  thus  prevent  the  reposition  from  being  accom- 
plished. Various  instruments  have  been  presented  to  the  profession 
for  the  purpose  of  returning  the  cord;  but  I  have  less  confidence  in 
their  utility,  at  least  so  far  as  I  have  become  acquainted  with  them, 
than  with  the  manual  method,  by  which  a  few  cases  have  been  saved. 
When  the  waters  have  been  freely  discharged,  an  1  the  uterus  acts 
with  energy,  any  attempts  to  return  the  cord  will  almost  always  be 
unsuccessful. 

If  the  cord  can,  however,  be  carried  above  the  presenting  part,  by 
the  introduction  of  the  hand  in  the  vagina,  and  two  fingers  into  the 
uterine  cavity,  I  would  advise  placing  it  in  the  axilla,  if  possible,  or 
above  the  knees ;  and  if  these  can  not  be  effected,  to  carry  it  carefully 
from  one  side  to  the  other.  However,  it  too  frequently  happens,  that 
after  the  cord  has  been  raised  above  the  presenting  part,  it  immediately 
prolapses  again  on  the  removal  of  the  fingers.  This  has  sometimes 
been  prevented  by  introducing  a  piece  of  soft  sponge,  carrying  it 
upward  with  the  cord. 

2.  If  the  head  has  not  entered  the  pelvic  cavity,  but  is  still  at  the 
brim,  a  resort  to  turning  has  been  advised,  provided  the  os  uteri  be 
fully  dilated  and  not  rigid;  but  as  this  operation  is  ahvays  attended 
with  danger  to  the  mother,  we  should  not  too  hastily  nor  too  rashly 
decide  upon  it.  If  the  soft  parts  be  well  dilated,  the  pelvis  capacious, 
and  the  female  has  given  birth  to  one  or  more  children  previously,  the 
child  may  possibly  be  saved  by  the  operation;  but  the  accoucheur 
should  always  remember  that  no  interference,  of  whatever  nature,  is 
justifiable,  which  has  for  its  object  the  safety  of  the  child  at  the  risk 
of  injury  or  death  to  the  mother.  Where  turning  has  been  performed, 
about  seven  out  of  ten  children  have  lived:  the  consequences  to  the 
mother  are  not  given.  Merriman  advises  turning  only,  in  instances 
where  the  child  is  living,  as  known  by  the  pulsations  or  the  cord,  the 


472  KIN(;'s    KCLKCTIC    OIJSTETRICS. 

head  not  having  entered  the  pelvis,  the  parts  relaxed  and  os  uteri  well 
dilated,  and  the  pains  weak  and  inefficient;  and  even  then  it  should 
not  be  attempted,  unless  the  practitioner  has  had  some  experience  in 
the  operation.  Dr.  Collins  says :  "  As  to  turning,  the  risk  to  the 
mother  is,  in  the  majority  of  cases,  so  great  as  to  forbid  its  employ- 
ment, nor  do  I  think  the  practitioner  justified  by  the  circumstances  in 
so  greatly  hazarding  his  patient's  life." 

3.  If  the  head  has  escaped  into  the  vagina,  and  the  pulsations  of 
the  cord  are  felt,  and  especially  when  they  are  diminishing  or  becom- 
ing feeble,  the  delivery  may  be  hastened  and  the  child's  life  saved  by 
a  resort  to  the  forceps,  and  this  may  be  accomplished  with  but  very 
little  risk  to  the  mother.     The  forceps  must  be  carefully  applied,  so 
as  not  to  fix  the  cord  between  either  of  its  blades  and  the  head,  and 
the  extraction  must  be  as  rapid  as  possible,  but  always  consistent  with 
the  safety  of  the  mother.    Unfortunately,  however,  we  more  frequently 
find  the  child  destroyed  by  the  compression  of  the  cord,  before  the 
instrument  can  be  applied. 

4.  It  has  been  recommended  to  place  the  cord  in  the  angle  formed 
by  the  junction  of  the  sacrum  and  ilium,  where  it  will  be  less  exposed 
to  compression,  and  that  sacro-iliac  symphysis  is  to  be  selected,  which 
will  not  be  occupied  by  the  forehead  or  occiput.     This  has  sometimes 
proved  successful,  and  will  probably  answer  in  cases  where  the  pelvis 
is  large  and  the  head  small.     In  ordinary-sized  pelves  but  little  re- 
liance can  be  placed  in  this  method. 

5.  The  "postural  treatment,"  by  Professor  T.  Gaillard  Thomas, 
M.  D.,  of  New  York  city,  appears  to  have  been  more  generally  suc- 
cessful than  any  other  method.     This  method  consists  in  inverting  the 
uterine  axis  or  long  diameter,  by  placing  the  woman  upon  her  hands 
and  knees,  the  face  or  shoulders  resting  upon  a  pillow,  while  the  hips 
are  elevated  as  much  as  .possible,  so  that  if  the  membranes  are  not 
ruptured,  the  cord  will  sink  below  the  brim  and  toward  the  uterine 
fundus  by  gravitation  alone.     But  if  the  membranes  be  ruptured,  the 
patient  keeping  the  position  named,  the  accoucheur,  introducing  his 
whole  hand  into  the  vagina,  will  seize  a  loop  of  the  cord  between  his 
fore  and  middle  fingers  and  carry  it  up  to  the  pelvic  brim,  holding  it 
there  until  the  whole  of  it  has  glided  downward  along  the  anterior 
surface  of  the  child  toward  the  fundus.     The  woman  will  retain  her 
position  until  the  pains  have  engaged  the  presenting  part  in  the  brim 
to  such  an  extent  that  there  is  no  longer  any  danger  of  a  renewal  of 
the  prolapsus,  when,  she  may  be  carefully  turned  upon  her  back,  and 
the  labor  be  allowed  to  proceed  as  usual.     As  this  position  tends,  from 


PRETERNATURAL  LABOR — TRANSVERSE   PRESENTATIONS,  ETC.  473 

gravitation,  to  delay  the  entrance  of  the  presenting  part  into  the 
pelvic  cavity,  however  strong  and  regular  the  pains  may  be,  the  ac- 
coucheur, passing  a  hand  each  side  of  the  patient,  should  lock  the 
fingers  of  the  hands,  and  make  sufficiently  strong  pressure,  during 
each  pain,  in  a  direction  toward  the  superior  strait,  so  as  to  sustain  the 
weight  of  the  uterus  and  its  contents,  as  well  as  to  keep  the  presenting 
part  in  close  proximity  with  the  brim.  And  during  the  intervals  the 
uterus  may  be  sustained,  so  as  to  prevent  recession  of  the  presenting 
part,  by  means  of  a  folded  blanket  or  firm  cushion  placed  between  it 
and  the  bed. 

If  the  prolapsus  be  ascertained  at  an  early  period  of  the  stage  of 
labor,  it  will  be  unnecessary  to  place  the  woman  in  the  above  position, 
[which  is  very  irksome,  and  which  may  also,  when  long  continued, 
occasion  a  sense  of  suffocation  from  pressure  upon  the  diaphragm], 
until  this  stasje  is  Dearly  terminated,  or  until  there  is  indication  that 

O  •/  ' 

the  presenting  part  will  shortly  engage  in  the  brim — the*  membranes, 
of  course,  being  unruptured. 

If  the  membranes  are  ruptured,  and  the  funis  when  carried  to  the 
brim  does  not  glide  toward  the  uterine  fundus,  it  will  be  necessary  to 
carry  the  hand  and  cord  within  the  uterine  cavity,  even  as  far  as  the 
child's  breast. 

The  position  is  not  an  elegant  one,  and  many  women  will  object  to 
or  decidedly  oppose  it;  but  when  it  is  fully  explained  to  them,  the 
reasons  therefor,  and  the  dangers  to  the  child,  few  mothers  will  persist 
in  their  opposition.  An  inclined  plane  can  be  arranged  with  the  bed 
clothing  or  otherwise,  with  a  soft  covering  upon  which  the  woman 
can  rest,  and  which  will  be  much  easier  and  less  objectionable  to 
her,  besides  obviating  the  necessity  for  the  support,  named  above,  to 
the  uterine  tumor. 

Of  these  various  modes,  the  selection  must  be  left  to  the  judgment 
of  the  accoucheur,  who  will  determine  according  to  the  stage  of  the 
labor,  the  condition  of  the  soft  parts  and  os  uteri,  the  conformation  of 
the  pelvis,  the  presenting  part  of  the  child,  and  various  other  circum- 
stances which  may  be  present.  In  a  premature  labor,  I  should  advise 
no-  other  interference  than  that  named  in  method  No.  4.  No.  5, 
the  "postural  treatment,"  will,  however,  be  found  the  best,  suitable 
for  nearly,  if  not  quite,  all  cases,  rendering  a  recourse  to  turning  or 
instruments  wholly  unnecessary. 

The  patient's  friends  should  always  be  informed  of  the  fact,  when 
there  is  a  prolapsus  of  the  funis,  together  with  the  great  probability 
of  the  child's  being  still-born ;  and  should  she  exhibit  any  surprise  or 


474  KING'S  ECLECTIC  OHSTETRICS. 

uneasiness  at  our  uncommon  attentions,  there  is  no  harm  in  acquaint- 
ing her  that  "the  cord  has  fallen  down,  adding,  however,  that  it  will 
not  interfere  with  the  labor  in  the  least,  but  may  occasion  the  child's 
death;"  nor  would  there  be  any  impropriety  in  explaining  to  her  the 
uses  of  the  cord,  and  the  reasons  why  the  child  may  be  lost,  as  well 
as  the  necessity  for  the  measures  about  to  be  pursued. 

It  is  also  proper  to  have  the  ordinary  means  for  resuscitating  the 
child  in  readiness,  and  which  should  be  used  in  all  instances  when 
delivery  has  been  effected  shortly  after  the  cessation  of  the  pulsations 
of  the  cord,  the  slightest  action  of  the  heart  being  a  sufficient  cause 
for  attempting  resuscitation. 

Professor  Meigs  suggests  the  following  measures  in  prolapse  of  the 
funis,  which,  however,  had  not  been  tried  by  himself;  "  Take  a 
piece  of  ribbon  or  tape,  a  quarter  of  an  inch  wide  and  four  or  five 
inches  long.  Half  an  inch  from  the  end,  fold  the  tape  back,  and  sew 
the  edges  so  as  to  make  a  small  pocket.  Then  fold  the  other  end  in  the 
opposite  direction,  and  sew  that  also  to  make  a  pocket  of  it.  Now,  if 
the  cord  be  taken  in  the  tape,  and  held  as  in  a  sling,  a  catheter  may  be 
pushed  into  one  of  the  pockets,  and  that  one  thrust  into  the  other,  so 
that  we  shall  have  the  cord  held  as  in  a  sling,  which  is  itself  supported 
on  the  end  of  the  catheter  or  uterine-sound.  Let  the  catheter  be  now 
pushed  up  into  the  womb,  beyond  the  fetal  head :  it  will  carry  the 
secured  portion  of  cord  with  it,  and  the  catheter  being  withdrawn,  the 
tape  is  left  in  the  uterine  cavity,  where  no  harm  can  be  occasioned  by 
its  presence.  If  required,  several  such  tapes  could  be  secured  round 
the  cord,  and  all  of  them  fixed  on  the  end  of  the  same  catheter,  and 
pushed  at  the  same  moment  far  up  within  the  cavity  of  the  womb." 
This  plan  may  answer  in  some  cases,  but  I  doubt  its  general  applica- 
tion. Dr.  Arneth  has  succeeded  in  saving  ten  out  of  eleven  cases,  by 
carrying  up  the  cord,  with  the  introduction  of  the  whole  hand  into  the 
uterine  cavity. 

In  a  previous  part  of  this  work  I  have  made  some  observations 
relative  to  COMPOUND  or  MULTIPLE  PREGNANCY,  the 
signs  by  which  it  may  be  suspected  or  recognized,  and  the  several 
circumstances  under  which  it  may  be  present.  At  this  place  I 
shall  refer  more  particularly  to  the  management  required  for  such 
cases  According  to  statistics  laid  down  by  Churchill  in  his  work 
on  Obstetrics,  167,676  cases  occurring  in  British  practice,  2,572 
were  twins,  or  about  1  in  651;  and  37  were  triplets,  or  1  in  4,531  J. 
In  36,570  cases  in  French  practice,  there  were  332  twins,  or  about  1 


PRETERNATURAL  LABOR — TRANSVERSE  PRESENTATIONS,  ETC.      475 

in  110;  and  6  triplets,  or  1  in  6,095.  In  German  practice,  251,386 
cases  gave  2,967  twins,  or  about  1  in  84 ;  and  35  of  triplets,  or  about 
1  in  7,185.  The  average  occurrence  of  the  whole,  455,632  cases,  would 
be  5,871  of  twins,  or  1  in  77| ;  and  78  of  triplets,  or  1  in  5,840. 

In  the  plurality  of  children,  or  where  women  give  birth  to  two  or 
more,  the  danger  is  always  greater  than  in  single  pregnancies,  being 
about  1  in  20 ;  yet  many  females  are  promptly  delivered  with  but  little 
more  pain  than  in  cases  where  one  child  is  born.  The  danger  in  these 
is  owing  principally  to  an  over-distension  of  the  uterus ;  to  a  preter- 
natural presentation  of  one  or  both  children ;  to  hemorrhage  after  the 
expulsion  of  the  placenta,  the  uterus  contracting  feebly  or  not  at  all  ; 
and  not  unfrequently,  inflammation  of  the  veins  and  deep-seated 
structures  of  the  uterus  occurs,  terminating  fatally. 

The  mortality  to  the  children  in  twin  births  is,  according  to  statis- 
tics, about  1  in  3  J ;  in  triplets,  1  in  3.  Though  it  must  be  recollected 
that  in  this  calculation  the  death  of  the  child  can  not,  in  every 
instance,  be  attributed  to  the  labor.  In  184  twin  cases  recorded,  4& 
were  still-born ;  and  in  240,  premature  labor  occurred  54  times,  with 
12  cases  of  a  putrid  fetus.  The  fatality  appears  to  be  greater  among 
male  children,  and  especially  when  they  are  twin  cases  of  opposite 
sexes.  These  statistics  are  based  upon  the  records  of  various  accouch- 
eurs, and  may  be  found  in  detail  in  Churchill's  Midwifery. 

DIAGNOSIS. — The  difficulty  in  diagnosing  twins  during  pregnancy 
has  already  been  spoken  of;  but  at  the  time  of  labor,  after  the 
expulsion  of  the  first  child,  the  presence  of  a  second  can  be  positively 
determined,  and  it  is  the  duty  of  the  practitioner  to  institute  a  proper 
examination,  that  he  may  have  no  doubts  upon  the  subject.  A  plurality 
of  children  may  be  suspected,  from  the  uncommon  size  and  shape  of 
the  abdomen,  though  it  is  frequently  the  case  that  in  this  respect  the 
female  is  not  larger  than  those  who  carry  but  one  child;  from  the 
feeble  and  irregular  action  of  the  uterus,  even  after  the  labor  has  con- 
tinued for  several  hours;  and  from  the  slowness  with  which  the  bag 
of  waters  is  formed.  After  the  delivery  of  the  first  child,  its  small 
size  may  likewise  occasion  us  to  suspect  that  there  is  another.  Yet 
these  various  circumstances  may.be  present,  and  the  case  be  one  of 
single  pregnancy. 

It  is,  therefore,  required  of  the  accoucheur,  in  every  case  of  labor 
which  he  may  attend,  immediately  after  the  birth  of  the  first  child,  to 
place  his  hand  on  the  abdomen  of  the  mother,  for  the  purpose  of 
ascertaining  whether  there  be  a  second  child ;  if  there  be  another,  he 
will  find  the  uterus  still  hard,  large,  and  unequal;  the  fund  us  remain- 


476  KING'S  ECLECTIC  OBSTETRICS. 

ing  at  the  epigastrium,  or  considerably  above  the  umbilicus,  and 
occupying' nearly  as  much  space  as  previous  to  the  birth  of  the  first. 
He  should  not,  however,  stop  at  this  external  exploration;  it  is 
absolutely  necessary  that  he  positively  ascertain  not  only  the  presence 

'of  another  child,  but  likewise  its  presentation  and  position;  and  to 
effect  this  will  require  an  internal  examination.  Holding  the  cord  of 
ihe  first  child  tense  with  one  hand,  but  without  making  any  traction 
upon  the  placenta,  he  will  pass  one  or  two  fingers  of  the  other  hand 
along  the  cord,  and  if  another  child  be  present,  the  fingers  will  come 
in  contact  with  the  second  bag  of  membranes,  when  he  should  correctly 
ascertain  the  nature  of  the  presentation,  after  which  it  will  always  !><• 

.  proper  for  him  to  inform  the  husband  or  nurse  of  the  fact ;  but  it 
should  not  be  immediately  made  known  to  his  patient,  lest  such  a 
depressing  influence  on  her  mind  be  caused,  as  to  materially  retard  the 
delivery  of  the  second  child.  No  particular  secresy  is  necessary, 
but  the  time  of  giving  the  information  to  the  patient  should  depend 
much  upon  her  mental  and  physical  condition,  and  the  circumstances 
connected  with  her  case.  It  may  be  proper  to  observe  here,  that 
practitioners  have  been  deceived  in  both  their  external  and  internal 
examinations,  having  mistaken  a  large  placenta,  a  large  quantity  of 
coagula,  an  accumulation  of  blood  behind  the  membranes  of  the 
retained  placenta,  etc.,  for  the  sac  of  another  child:  on  rupturing  these, 
the  escape  of  blood  or  coagula,  instead  of  the  amniotic  fluid,  will  at 
once  solve  the  case. 

TREATMENT. — Usually,  there  are  no  suspicions  of  a  twin  labor 
until  after  the  birth  of  the  first  child,  and  the  delivery  may  proceed  as 
favorably  as  in  single  cases.  But  it  frequently  happens  that  the  force 
and  frequency  of  the  pains  become  greatly  diminished,  in  consequence 
of  the  uncommon  distension  of  the  uterus;  or  the  contractions  being 
energetic,  the  delivery  progresses  slowly,  because  the  contracted  uterus 
can  not  act  directly  upon  the  whole  of  the  body  of  the  child  which 
first  reaches  the  superior  strait.  And  in  cases  of  premature  labor 
occasioned  by  twin  pregnancy,  the  delivery  may  be  delayed,  from  the 
immatured  condition  of  the  cervix  uteri,  which  has  not  undergone 
those  changes  which  facilitate  its  dilatation  at  full  term. 

When  the  practitioner  suspects  twin  labor  in  a  case  where  the  delivery 
of  the  first  is  proceeding  very  slowly,  and  more  especially  when  his 
suspicions  are  strengthened  by  hearing  sounds  of  the  fetal  heart  at  two 
distinct  locations,  he  must  be  very  cautious  how  he  ventures  to  admin- 
ister Ergot,  or  other  agents  to  increase  the  action  of  the  uterus,  prior 
to  the  birth  of  the  first  child:  no  interference  of  this  kind  is  required, 


PRETERNATURAL  LABOR TRANSVERSE  PRESENTATIONS,  ETC.   477 

or  at  all  necessary.  The  labor  should  be  allowed  to  proceed,  no  mat- 
ter how  slowly,  until  the  first  child  is  born.  But  should  any  accidents 
or  circumstances  offer  requiring  aid,  they  should  be  treated  in  the 
same  manner  as  recommended  when  they  occur  in  single  labors; 
being  careful,  however,  should  a  resort  to  turning  be  deemed  advisa- 
ble, as  in  a  shoulder  presentation,  to  obtain  a  hold  of  the  feet  of  the 
right  child  before  making  the  evolution.  If  the  children  arc  con- 
tained in  one  sac,  or  if  there  are  two  sacs  and  both  have  become  rupt- 
ured, a  difficulty  in  relation  to  this  matter  will  be  very  apt  to  occur. 
By  passing  the  hand  along  the  external  part  of  the  limbs,  until  it 
reaches  the  breech  or  genital  organs,  we  may  avoid  the  mistake  of 
bringing  down  a  limb  of  each  child.  As  a  rule,  each  child  has  its  own 
bag  of  membranes,  and  its  own  placenta,  and  the  placenta  of  the  child 
born  first  should  not  be  removed,  until  after  the  birth  of  the  second 
child,  as  it  will  almost  certainly  give  rise  to  more  or  less  serious  hem- 
orrhage. 

As  I  have  already,  when  treating  on  the  Management  of  Labor, 
recommended  two  ligatures  to  the  umbilical  cord,  previous  to  separat- 
ing it,  it  is  unnecessary  to  enter  into  any  special  remarks  upon  the 
subject  at  this  place.  After  the  birth  of  the  first  child,  if  the  presen- 
tation of  the  second  is  proper,  and  the  contractions  of  the  uterus  con- 
tinue, no  interference  is  necessary;  indeed,  it  not  unfrequently  hap- 
pens that  the  pains  are  so  energetic,  and  the  expulsion  so  rapid,  that 
the  second  child  is  born  before  the  first  can  be  separated  from  its 
cord.  But  in  cases  where  there  are  no  pains  after  the  birth  of  the 
first  child,  or,  when  they  are  present,  but  feeble  and  inefficient,  means 
should  be  used  to  forward  them,  after  having  waited  some  fifteen  or 
twenty  minutes.  A  bandage  should  be  firmly  applied  around  the 
abdomen,  frictions  and  compression  should  be  made  over  it  upon  the 
uterus,  and  as  the  passages  are  already  dilated  there  is  no  objection  to 
the  administration  of  Ergot;  in  fact,  if  there  is  delay  in  normal  ex- 
pulsive action,  its  judicious  administration  is  commended,  or  stim- 
ulants, if  necessary,  should  likewise  be  exhibited  internally.  Should 
the  second  child  present  naturally,  that  is,  either  the  head  or  breech 
presenting  at  the  brim,  and  half  an  hour  or  an  hour  has  passed  since 
the  birth  of  the  first,  the  application  of  the  bandage,  together  with  the 
artificial  rupture  of  the  membranes,  will  generally  occasion  a  renewal 
*of  the  contractions,  and  delivery  will  be  terminated  without  any 
further  interference. 


478  KING'S  ECLECTIC  OBSTETRICB. 

In  ordinary  eases,  where  the  pains  do  not  return,  notwithstanding 
the  means  employed,  I  would  not  advise  the  accoucheur  to  wait  beyond 
an  hour;  because  the  parts  being  yet  soft,  dilatable,  and  amplified 
from  the  expulsion  of  the  first  child,  the  second  may  be  expelled  with 
more  facility,  and  with  less  suffering  to  the  mother,  than  would  be  the 
•case  if  a  longer  delay  was  permitted.  The  hour  having  therefore 
expired,  and  no  return  of  uterine  action,  the  presentation  of  the  second 
child  being  known,  the  parts  being  soft  and  yielding,  and  the  os  uteri 
dilatable,  the  membranes  should  be  ruptured,  and,  if  necessary,  the 
hand  passed  upward  to  reach  the  feet,  and  the  evolution  proceeded  with 
according  to  the  rules  already  given,  being  very  careful  not  to  empty 
the  uterus  of  its  fetus  before  contractions  come  on.  Too  sudden  an 
evacuation  of  the  uterus  may  give  rise  to  hemorrhage,  inversion,  or 
other  accidents. 

Turning,  however,  must  never  be  attempted  when  the  resources  of 
nature  are  adequate  to  the  expulsion  of  the  child. 

After  the  delivery  of  the  first  child,  the  parts  of  the  female  being 
soft  and  yielding,  and  also  sufficiently  amplified  by  its  expulsion,  a  foot 
or  breech  delivery  of  the  second  child,  either  natural  or  effected  arti- 
ficially, is  by  no  means  so  difficult  or  so  painful  to  the  mother,  as  in 
similar  labors  with  but  one  child  ;  nor,  as  a  general  thing,  is  the  safety 
of  the  child  so  greatly  compromised.  In  a  shoulder  presentation  of 
the  last  child,  cephalic  version,  according  to  Dr.  Wright's  method,  in 
the  last  chapter,  might  probably  be  performed  with  success. 

Sometimes,  the  female  becoming  very  much  fatigued  and  worn  out 
by  the  tediousness  of  a  twin  labor,  may  require  artificial  aid,  as  for 
instance,  with  the  forceps,  for  the  delivery  of  the  first  child ;  and  in 
such  cases,  it  will  generally  be  found  advantageous  as  well  as  necessary 
to  expedite  the  delivery  of  the  second  by  bestowing  similar  assistance. 
Interference  will  always  be  demanded  during  the  expulsion  of  the 
second  child,  when  it  presents  transversely,  or  when  it  is  complicated 
with  convulsions,  hemorrhages,  or  other  accidents.  And  these  com- 
plications must  be  combated  according  to  the  rules  advised  for  them, 
when  occurring  in  single  labors. 

Hemorrhage  is  always  to  be  dreaded  in  twin  births,  and  must  be 
most  carefully  watched  ;  it  may  almost  always  be  ascertained  at  an 
early  period,  even  before  the  practitioner  would  be  led  to  suspect  it 
from  the  character  of  the  discharge  externally,  by  closely  observing 
the  expression  and  color  of  the  patient's  face.  When  hemorrhage 
occurs  before  the  birth  of  the  second  child,  it  will  demand  prompt 
action,  the  labor  must  be  hastened  by  turning,  if  the  presenting  part 
is  above  the  superior  strait — by  the  forceps,  when  the  head  is  in  the 


PRETERNATURAL    LABOR — TRANSVERSE    PRESENTATIONS,  ETC.  479 

pelvic  cavity.  Hemorrhage  after  the  birth  of  the  second  child,  must 
be  treated  as  hereafter  recommended  for  hemorrhage  occurring  previ- 
ous to,  or  after,  the  birth  of  the  placenta,  as  may  be. 

Occasionally,  there  will  be  a  simultaneous  presentation  of  parts  of 
the  two  children,  as,  the  two  heads,  the  feet  or  arms  of  each,  or  the 
head  of  one  with  the  extremities  of  the  other,  etc.  In  these  cases,  it 
will  be  necessary  to  push  up  one  of  the  presenting  parts,  in  order  that 
the  remaining  one  may  advance ;  and  should  these  double  presenta- 
tions prevent  the  labor  from  progressing  safely,  a  resort  to  instrumental 
aid  may  be  demanded,  as  decapitation  of  one  child,  or  such  other 
measures  as  the  exigency  of  the  case  may  require. 

The  practitioner  must  recollect  that  in  twin  labors,  one  placenta  may 
be  common  to  both  children,  or,  there  may  be  a  placenta  to  each  child, 
but  connected  with  each  other  marginally ;  and,  an  improper  manage- 
ment of  either  of  these  conditions  may  occasion  dangerous  hemorrhage. 
No  attempts  at  removing  the  placenta  of  the  first  child  should  be  made 
previous  to  the  delivery  of  the  second,  as  uncontrollable  hemorrhage 
might  thereby  be  excited.  And,  after  £he  expulsion  of  the  second 
child,  a  much  longer  interval  than  in  ordinary  cases  must  be  allowed 
for  the  delivery  of  the  placenta  (unless  the  presence  of  hemorrhage 
renders  its  prompt  removal  necessary),  as  the  uterus  being  somewhat 
enfeebled  or  exhausted,  does  not  so  readily  renew  its  contractions  as 
in  single  labors.  The  removal  of  the  placentae  must  never  be  effected 
by  forcible  traction  upon  the  cord,  but  by  arousing  and  securing 
permanent  uterine  contractions,  using  frictions  and  compressions 
externally,  and  making  slight  tractions  upon  the  cord,  as  heretofore 
recommended  in  single  labors. 

In  hemorrhages,  after  the  birth  of  the  last  oirild,  the  hand  will 
require  to  be  introduced  within  the  uterine  cavity,  in  order  to  detach 
and  remove  the  placentae;  and  it  should  not  be  withdrawn,  until  a 
perfect  separation  of  both  has  been  accomplished — and  even  then,  not 
until  uterine  action  has  been  aroused  sufficiently  to  induce  due  and 
permanent  contractions  of  the  organ.  After  the  placentas  have  been 
removed,  their  uterine  surfaces  should  invariably  be  examined,  to  as- 
certain whether  any  part  has  been  left  behind  within  the  uterus. 

In  cases  where  a  premature  labor  has  been  induced  by  the  presence 
of  twins  within  the  uterine  cavity,  and  the  first  child  has  been  expelled, 
the  recommendations  to  rupture  the  membranes,  or  in  any  way  hasten 
the  delivery  of  the  second,  is  exceedingly  unwise  and  improper ;  this 
recommendation  is  only  applicable  at  full  term.  After  the  escape  of 


480  KING'S    ECLECTIC    OBSTETRICS. 

the  first  child,  should  the  uterus  cease  any  further  action,  the  second 
remaining  one  may  be  matured  by  a  further  continuance  of  the  preg- 
nancy, and  this  result  should  always  be  favored  by  non-interference, 
unless  accidents  occur  threatening  the  mother's  life,  and  rendering  it 
imperative  to  empty  the  uterus  of  its  contents. 

After  the  expulsion  of  the  placentae,  the  bandage  should  be  firmly 
applied  around  the  abdomen,  with  a  compress  over  the  uterine  tumor, 
to  secure  its  permanent  contraction,  and  prevent  any  tendency  to 
hemorrhage;  and  as  the  shock  to  the  nervous  system  is  usually  much 
more  severe  than  in  natural  labors,  the  patient  must  be  kept  quiet,  the 
presence  of  company  rigidly  prohibited,  and  stimulants,  antispas- 
modics,  or  anodynes,  administered  according  to  the  indications. 
Uterine  hemorrhage  should  always  be  closely  watched  for,  and  every 
means  be  employed  to  guard  against  it.  And  the  accoucheur  should 
not  leave  bis  patient  until,  by  feeling  through  the  abdominal  wall, 
he  has  found  the  uterus  about  the  size  of  a  fetal  head  and  firmly 
contracted. 

Where  three  or  more  children  are  present,  they  will  require  to  be 
managed  in  accordance  with  the  above  rules,  recollecting  that  the 
labor  will  generally  proceed  slowly,  but  that  the  dilatation  of  the  soft 
parts  will  not  be  so  extensive,  nor  the  sufferings  to  the  mother  so  great 
as  in  labors  of  one  or  two  children,  from  the  fact  that  triplets  and 
quadruplets  are  usually  very  small.  Hemorrhage,  however,  is  always 
to  be  suspected. 

In  plural  births,  every  variety  of  presentation  may  occur;  thus, 
the  head  of  the  first  child,  and  the  breech  of  the  second,  which  are 
favorable  positions ;  the  head  of  each  may  present ;  the  breech  or 
shoulder  of  one,  and  the  head  of  the  other ;  each  child  may  present 
by  a  shoulder;  together  with  other  varieties,  rendering  it  highly 
necessary  for  the  accoucheur  to  be  conversant  with  the  modes  of  diag- 
nosticating each  and  all  of  them.  Cazeaux  observes:  "Pleissman 
states  that,  on  one  occasion,  he  found  the  orifice  plugged  up  by  the 
parts  that  had  become  engaged,  and  which  at  first  sight  appeared  to 
him  to  be  a  quantity  of  hands  and  feet.  A  more  careful  examination 
enabled  him  to  distinguish  four  inferior  extremities,  which  were 
delivered  as  far  as  the  hand,  and  one  arm. 

"'At  first,'  he  says,  'I  was  in  great  perplexity,  because  I  could  find 
no  way  of  introducing  my  hand  into  the  womb,  for  the  purpose  of 
distinguishing  and  seizing  the  two  feet  belonging  to  each  child,  and 
because  all  my  efforts  to  make  even  one  of  these  extremities  go  back 


PRETERNATURAL,  LABOR — TRANSVERSE  PRESENTATIONS,  ETC.   481 

again,  proved  abortive ;  beside  which,  in  drawing  on  any  two  of 
them,  I  might  confound  and  bring  down  the  feet  of  two  different 
fetuses  at  the  same  time  ;  and  lastly,  even  if  I  succeeded  in  seizing 
the  two  feet  belonging  to  the  same  infant,  I  might,  by  drawing  on 
them,  engage  the  other  parts,  and  thus  augment  the  difficulties.  Being 
greatly  embarrassed  as  to  the  proper  course,  and  yet  obliged  to  act, 
the  employment  of  a  measure  recommended  by  Hippocrates,  under 
different  circumstances,  happily  suggested  itself;  that  was,  to  suspend 
the  patient  by  her  feet,  hoping  that  the  heads  and  the  trunks  of  the 
children  would,  by  their  weight,  draw  one  or  more  of  the  extremities 
toward  the  fundus  of  the  womb,  which  was  still  distended  by  the 
waters.  The  husband  and  brother-in-law  of  the  woman  passed  their 
arms  under  her  hams,  and  thus  held  her  suspended,  so  that  only  the 
head  and  shoulders  rested  on  the  bolster.  I  intended,  as  soon  as  I 
mounted  on  the  bed,  to  press  back  one  or  more  of  the  free  extremities 
into  the  womb,  but  two  had  already  returned  from  the  mere  position 
of  the  mother,  and  the  other  three  soon  followed  by  the  aid  of  my 
fingers.  Immediately  afterward,  I  was  enabled  to  introduce  my  hand 
into  the  uterus,  and  to  withdraw  successively  therefrom  three  children 
by  the  feet.'  In  bringing  forward  this  case,  I  only  desire  to  illustrate 
what  has  been  said  concerning  the  difficulty  of  diagnosis.  I  ought 
also  to  allude  to  the  impossibility  of  the  reduction,  and  the  singular 
procedure  resorted  to,  with  a  success  that  seems  to  warrant  its  employ- 
ment again  under  similar  circumstances." 

Ramsbotham  detected,  by  the  direction  of  the  toes,  that  two  feet 
presenting  at  the  vulva,  a  right  and  left,  belonged  to  different  bodies ; 
he  terminated  the  labor  by  making  careful  traction  at  one  leg,  and 
gently  pushing  up  the  other,  extricating  each  breech  from  the  pelvic 
brim,  and  the  children  were  born  living.  Such  cases,  as  before 
observed,  occur  when  the  children  are  in  one  sac,  or  when  the  sac  of 
each  ruptures  before  the  child  is  expelled. 

The  most  difficult  complication  of  presentation  is  where,  as  the  first 
child  descends,  with  the  pelvic  extremity  first,  its  chin  becomes  locked 
under  the  chin  of  the  other,  "which  was  presenting  the  head,  and  which 
had  passed  into  the  pelvic  cavity.  In  this  case  only  one  child  can  be 
saved  ;  the  child  which  has  descended  must  be  eviscerated  and  detrun- 
cated, leaving  its  head  in  the  uterine  cavity ;  this  must  be  pushed  up 
above  the  superior  strait,  the  second  child  brought  down  and  delivered, 

and  finally  the  head  of  the  first  must  be  removed, 
31 


482  KING'S  ECLECTIC  OBSTETRICS, 

The  fetus  is  subject  to  various  diseases,  and  to  excessive  develop- 
ment, or  perversion  of  parts,  while  within  the  uterus,  which  may  form 
MONSTERS  or  MONSTROSITIES,  and  which  frequently  exert  an 
mi  favorable  influence  upon  the  parturition.  The  difficulty  in  these 
cases  depends  altogether  upon  the  relative  proportion  between  the 
fetus  and  the  pelvis;  if  the  child  be  small,  there  will  be  no  delay  or 
trouble  in  its  passage  through  the  pelvis ;  if  it  be  large,  from  excessive 
development,  or  from  a  union  of  two  fetuses  in  one,  the  labor  will  be 
difficult  and  preternatural  according  to  the  disproportion  existing  and 
other  circumstances  which  may  offer. 

Hydrocephalus,  ascites,  and  distension  of  the  abdomen  with  wind, 
or  water,  are  the  most  common  diseases  incident  to  the  fetus  which 
render  labor  difficult;  these  have  already  been  treated  upon. 

Monsters  are  occasionally  met  with  in  practice,  and  mainly  belong 
to  one  of  the  following  classes,  viz.:  1.  Monstrosity  from  deficiency 
of  certain  parts  of  the  body,  as,  in  anopses,  where  the  eye  and  orbit 
are  wanting;  cyclopes,  where  there  is  but  one  eye,  situated  in  the 
center  of  the  forehead ;  acephalous,  where  the  head  is  absent ;  anen- 
cephalous,  where  the  head  is  present,  but  is  devoid  of  brain,  etc.  2. 
Double  monstrosity,  where  two  or  more  children  become  united 
together,  as  in  cephalodymia,  where  the  heads  grow  together ;  hepato- 
dymia,  where  the  livers  are  united;  pelvidymia,  where  the  pelvic 
extremities  become  fused,  etc.  3.  Monstrosity,  or  ectopy,  in  which 
one  or  several  parts  are  abnormally  situated.  4.  Where  clefts  or 
fissures  occur  in  parts  which  are  united  when  in  a  normal  condition. 
5.  Where  there  is  am  excess  or  disproportionate  enlargement  of  certain 
parts.  6.  Atresia,  or  where  parts  which  are  normally  opened  become 
closed.  7.  Hermaphroditism,  or  vicious  conformation  of  the  genital 
organs.  Various  causes  have  been  assigned  for  these  monstrosities, 
among  which  the  most  probable  are :  1.  A  primitive  defect  in  the 
germs ;  2.  Accidental  changes  undergone  by  the  fetus  at  some  period 
of  its  intra-uterine  life,  effected  by  the  imagination  of  the  mother, 
injuries,  an  unhealthy  condition  of  the  mother,  etc. 

In  an  obstetrical  point,  the  only  instances  which  are  of  interest, 
from  their  sometimes  creating  a  very  painful  and  difficult  delivery,  are 
those  belonging  to  the  above  2d,  3d,  and  5th,  classification',  the  2d, 
more  especially :  and  when  they  do  occur,  it  is  almost  impossible  for 
an  accoucheur  to  form  a  correct  diagnosis.  But  even  should  he  be 
able  to  detect  a  monstrosity,  it  does  not  follow  that  he  should  inter- 
fere, for  the  natural  efforts  are  frequently  adequate  to  the  task  of 


PRETERNATURAL  LABOR — TRANSVERSE  PRESENTATIONS,  ETC.  483 

terminating  labor,  and   even   without  loss  of  the  child's  life,  as  for 
instance,  in  the  cases  of  the  Siamese  twins,  and  Rita  Christina. 

Double  monstrosity,  or  the  adherence  of  two  fetuses  may  be  sus- 
pected only  by  evidence  of  a  negative  character.  "  If  two  bags  of 
water  are  detected  by  the  finger,  if  it  is  necessary  to  rupture  the  mem- 
branes twice,  if  the  amniotic  waters  are  discharged  at  two  separate  and 
distinct  periods,  the  presence  of  independent  twins  in  the  womb  may 
be  regarded  as  certain ;  for  there  are  never  two  envelopes  for  a  double 
monster,  and  two  perfect  twins  are  very  seldom  shut  up  in  the  same 
amniotic  pouch.  Again,  if  two  feet  or  even  a  single  one  descend  with 
the  head,  more  particularly  if  the  feet  yield  to  the  tractions  made  on 
them,  and  appear  at  the  vulva  without  the  heads  having  a  tendency  to 
reascend,  we  may  affirm  there  are  two  infants,  because  a.  monster  is 
never  composed  of  two  individuals  held  together  in  such  a  way  that 
the  head  of  one  is  alongside  the  feet  of  the  other;  but  if  several  limbs 
present  simultaneously,  we  can  only  ascertain  whether  the  children  to 
which  they  respectively  belong  are  joined  together  or  are  independent, 
by  carrying  the  hand  up  into  the  womb."  (Cazeaux.} 

TREATMENT. — The  management  of  monstrosities  is  similar  to 
that  heretofore  named,  in  cases  of  difficult  labor.  A  fair  trial  should 
always  be  accorded  to  the  eiforts  of  nature ;  if  after  having  waited  a 
sufficient  length  of  time,  say  for  twenty-four  hours,  during  which  time 
the  pains  have  been  strong  and  active,  if  delivery  is  not  effected, 
means  should  then  be  adopted  to  expedite  it.  Or,  should  symptoms 
-of  exhaustion  manifest  themselves  previous  to  this  time,  or  hemor- 
rhage, or  other  accidents,  the  accoucheur  should  at  once  interfere.  No 
specific  rule  can,  however,  be  given  ;  the  general  principles  of  obstetrics 
must  be  the  guide ;  the  success  attending  the  case  will  depend  alto- 
gether upon  the  skill  and  judgment  of  the  attendant,  who  will  resort 
to  the  forceps,  perforator,  crotchet,  etc.,  according  to  the  peculiar  cir- 
cumstances of  the  case ;  and  who  should  not  hesitate  to  destroy  or 
mutilate  the  child,  if  it  become  necessary,  in  order  to  insure  the  safety 
of  the  mother.  In  case  of  great  pelvic  deformity,  the  Cesarean 
operation  may  become  necessary,  but,  with  a  normal  pelvis,  the  de- 
formity of  the  child  must  be  very  excessive,  which  should  lead  the 
practitioner  to  adopt  this  expedient  for  its  removal. 

When  monsters  live,  and  are  capable  of  action  as  individuals,  they 
have  the  same  rights  as  other  persons ;  and  the  destruction  of  a  monster, 
after  birth,  however  great  the  deformity,  is  a  criminal  act,  punishable 
as  infanticide.     This  should  not  be  forgotten,  as  I  have  heard  of  mid- 
wives  who  did  not  hesitate  to  destroy  monsters  as  soon  as  born. 


484  KING'S  ECLECTIC  OBSTETRICS. 


CHAPTER    XXXVI. 

COMPLICATED     LABOR UTERINE     HEMORRHAGE     FROM     PLACENTA 

PRvEVIA PUERPERAL    HEMORRHAGE PLACENTAL    PRESENTATION. 

ONE  of  the  most  common  complications  of  labor,  and  at  the  same 
time  the  most  alarming,  is  HEMORRHAGE  or  FLOODING.  It 
attacks  suddenly,  progresses  rapidly,  and  requires  prompt  and  ener- 
getic treatment;  equanimity,  self-possession,  caution,  and  a  thorough 
familiarity  with  the  appropriate  remedial  measures,  are  necessary  re- 
quirements for  success — without  these  the  individual  who  attempts  the 
practice  of  obstetrics  is  extremely  culpable.  No  one  can  tell  with 
certainty,  in  an  early  stage,  whether  hemorrhage  will  occur  during 
airy  given  labor;  and  it  is  not  unfrequently  the  case,  that  it  attacks 
suddenly  and  fatally  in  instances  where  least  expected  ;  no  one  can 
know  at  what  moment  he  may  be  called  to  treat  a  formidable  puerperal 
flooding — hence,  the  importance  of  holding  the  above  requirements. 
A  proper  attention,  may  insure  safety  to  two  human  beings,  while  an 
ignorant  or  ill-directed  course,  is  almost  certain  to  terminate  fatally. 

I  have  already  referred  to  abortion  and  the  hemorrhage  which 
may  be  present  in  the  early  months  of  gestation ,  this  may  be,  and 
is  at  times,  very  profuse,  often  resulting  in  the  death  of  the  patient. 
But  the  more  fearful  and  perilous  attacks  of  flooding  are  those  which 
take  place  at  the  parturient  period.  These  may  be  divided  into  four 
forms:  1st.  That  which  occurs  at  an  early  period  of  labor  from  pla- 
cental  presentation.  2d.  That  which  occurs  during  labor,  previous  to . 
the  birth  of  the  child,  but  not  dependent  upon  placenta  pra;via. 
3d.  That  which  occurs  after  the  birth  of  the  child,  but  previous  to  the 
expulsion  of  the  placenta.  4th.  That  which  takes  place  after  the 
delivery  of  the  placenta. 

In  75,596  cases  of  labor,  hemorrhage  occurred  517  times,  or  about 
1  in  146£;  out  of  630  cases  of  hemorrhage,  111  mothers  were  lost,  or 
about  1  in  5£;  out  of  443  cases,  109  children  were  lost,  or  about  1  in  4. 
In  accidental  hemorrhage,  28  cases  proved  fatal  out  of  114,  or  nearly 
1  in  4 ;  in  unavoidable  hemorrhage,  51  cases  proved  fatal  out  of  182, 
or  about  1  in  3£ ;  and  in  hemorrhage  after  delivery,  22  proved  fatal 
out  of  293  cases,  or  about  1  in  12.  (Churchill.} 


COMPLICATED    LABOE PUERPERAL    HEMORRHAGE,    ETC.        485 

The  placenta  may  vary  in  its  point  of  attachment  to  the  internal  face 
of  the  uterus;  thus,  in  one  class  of  cases  it  may  adhere  to  some  portion 
of  the  fundus,  in  another,  to  a  part  of  the  body,  and  in  others,  to  the 
inferior  segment  of  the  uterine  body,  partially  or  wholly  over  the  inner 
os  uteri,  and  hemorrhage  to  any  great  extent  will  not  take  place  in 
either  of  these  conditions,  during  gestation  or  parturition,  unless  the 
placenta  be  considerably  separated  from  the  uterine  surface.  A  slight 
detachment  may  occasion  a  discharge  of  blood  from  some  small  blood- 
vessels which  have  become  thereby  exposed,  but  insufficient  to  create 
alarm,  or  amount  to  a  flooding.  It  is  only  when  the  separation  has, 
from  any  cause,  become  so  extensive  as  to  expose  the  patulous  orifices 
of  the  large  veins  and  arteries  of  the  uterus,  through  which  the  utero- 
placental  circulation  has  been  carried  on,  that  a  quantity  of  blood 
escapes  giving  rise  to  puerperal  uterine  hemorrhage.  And  so  long  as 
these  orifices  remain  open,  whether  from  inertia  of  the  uterus,  or  from 
the  presence  of  a  body  within  its  cavity  which  prevents  its  perfect 
contraction  and  condensation,  .so  long  will  the  hemorrhage  continue. 
It  is  only  by  the  contraction  of  the  muscular  fibers  of  the  uterus,  that 
these  orifices,  as  well  as  the  caliber  of  the  whole  tract  of  the  bleeding 
uterine  vessels,  become  diminished  to  such  an  extent  as  to  permanently 
arrest  the  flooding.  And  to  adopt  means  for  the  purpose  of  effecting 
such  uterine  contraction  is  the  duty  of  every  accoucheur  who  treats 
puerperal  hemorrhage. 

HEMORRHAGE  FROM  PLACENTAL  PRESENTATION, 
or  PLACENTA  PR^EVIA,  in  which  the  placenta  is  located  "prse 
via"  before  the  passnge  or  way,  is  termed  unavoidable  hemorrhage ; 
it  is  the  most  dangerous  form,  and  the  most  difficult  to  manage.  The 
placenta  being  attached,  partially  or  completely,  over  the  inner  os 
uteri,  to  the  lower  segment  of  the  uterine  body,  as  the  fibers  of  the 
cervical  portion  of  the  uterine  body  become  more  and  more  developed 
during  the  latter  months  of  pregnancy,  in  order  to  enlarge  the  lower 
portion  of  the  uterine  cavity,  the  connection  between  the  placenta  and 
uterus  becomes  gradually  separated,  and  the  utero-placental  vessels 
being  thereby  ruptured  or  lacerated,  a  discharge  of  blood  follows, 
perhaps  some  from  the  placental  surface,  but  chiefly  from  the  uterine, 
proportionate  to  the  extent  of  separation  and  size  of  the  blood-vessels 
ruptured.  And  when  this  occurs  during  labor,  the  hemorrhage  grows 
more  excessive  with  the  advance  of  the  labor,  as  each  uterine  contrac- 
tion effects  an  increase  of  separation.  The  placenta  may  be  inserted 


486  KING  S    ECLECTIC    OBSTETRICS. 

immediately  over  the  inner  os  uteri,  so  that  the  centers  of  the  two 
are  in  correspondence,  when  it  is  called  complete  placenta  pnevia,  or 
Placenta  CentraUs;  or  it  may  vary  in  any  degree  between  this  central 
location  and  the  insertion  of  its  edge  near  the  os  intern  urn  uteri, 
when  it  is  called  partial  placenta  prsevia,  or  Placenta  Latcralis;  the 
danger  in  these  cases  increases  as  the  center  of  the  placenta  approach o 
that  of  the  inner  os  uteri.  The  fact  that  the  placenta  may  lie  over  the 
os  uteri,  was  noticed  by  several  of  the  older  French  writers,  among 
whom  may  be  named  Guillemeau,  Mauriceau,  Amand,  Astruc,  and 
Dionis,  as  well  as  by  others  who  have  written  since  the  middle  of  the 
eighteenth  century.  About  the  year  1728,  Daventer  called  the  attention 
of  the  profession  in  Holland  to  this  matter,  and  some  twenty-five 
years  later,  Bracken  and  Pugh  brought  the  subject  to  the  notice  of  the 
physicians  of  England. 

Although  these  writers  accurately  described  the  condition  of  things 
at  the  period  of  labor,  they  all  seem  to  have  entertained  the  opinion 
that  this  malposition  of  the  after-birth  was  owing  to  some  accident 
which  had  dislocated  it  from  its  former  connection  with  the  fuudus  of 
the  uterus,  and  that  it  had  gravitated  downward  by  its  own  weight, 
-  until  it  had  become  placed  in  its  new  position,  covering  more  or  less 
completely  the  orifice  of  the  organ. 

Such  an  opinion,  however,  does  not  obtain  with  the  well-informed 
of  the  profession  at  the  present  day,  all  agreeing  that,  inasmuch  as  the 
chorion,  the  decidua,  and  the  membranes,  as  well  as  the  blood-vessels, 
both  of  the  uterus  and  placenta,  maintain  the  same  relations  to  each 
other  when  the  placenta  is  found  in  this  position,  as  when  in  its  normal 
location,  that,  from  some  unknown  cause  it  must  have  been  attached, 
from  the  first,  in  the  lower  part  of  the  womb,  and  not  have  fallen  from 
a  former  attachment. 

As  early  as  in  1730,  Giffard  published  the  opinion,  that  he  had 
"good  reasons  to  believe  that  the  placenta  sometimes  adheres  to,  or 
near,  the  os  internum,  and  that  the  opening  of  it  occasions  a  separa- 
tion of  the  blood-vessels,  and  consequently  a  flooding."  A  similar 
opinion  was  expressed  by  Heister,  in  1739,  who  said  "some  moderns 
consider  as  a  cause  of  hemorrhage,  the  adhesion  of  the  placenta  to 
the  mouth  of  the  womb;  so  that  the  more  the  os  uteri  is  dilated,  the 
greater  is  the  separation  of  the  placenta,  and  the  more  profuse  the 
flooding."  In  1761,  Leveret,  and  in  1779,  Smellie,  expressed  similar 
views,  maintaining  that  the  placenta  was  from  the  first  over  the  os 
.  uteri,  and  that  its  being  there  was  not  the  result  of  a  detachment  from 


COMPLICATED    LABOR — PUERPERAL    F1EMO.RRHAGE,    ETC.        487 

the  fundus,  and  a  dislocation  of  the  organ.  This  opinion  has  uni- 
versally prevailed  among  scientific  men  since  that  time,  and  now 
requires  no  additional  proof  to  that  furnished  in  abundance  by  prac- 
tical men,  both  by  reason  and  by  observation.  Dr.  Rigby,  of  Nor- 
wich, England,  however,  was  the  first  to  call  attention  to  parturient 
hemorrhage,  and  the  importance  of  distinguishing  its  varieties,  that 
the  proper  treatment  might  be  pursued.  Since  which  placenta  prsevia 
has  received  the  closest  attention  of  several  eminent  accoucheurs  in 
Europe  and  the  United  States. 

Instances  of  placental  presentation  have  been  met  with,  in  which 
delivery  has  been  safely  accomplished  by  the  natural  powers  without 
any  hemorrhage  whatever,  but  they  are  very  rare,  and  are  never  to  be 
anticipated.  Most  commonly,  the  first  symptom  of  this  presentation 
is  a  gush  of  blood  occurring  sometimes  during  the  latter  months  of 
gestation,  from  the  seventh  month  to  full  term.  It  is  from  this  period 
that  the  cervical  portion  of  the  uterine  body  begins  to  rapidly  develop 
itself;  a  detachment  of  the  placenta  ensues  as  the  uterine  fibers  expand, 
and  a  discharge  of  blood  follows,  which  is  the  first  symptom  observed. 
Dr.  Barnes,  of  England,  does  not  believe  that  the  hemorrhage  in  these 
cases  is  owing  to  the  separation  of  the  placenta  from  the  gradual 
development  and  expansion  of  the  cervix,  but  to  the  growth  of  the 
placenta  itself.  He  says:  "The  first  detachment  of  placenta  arises 
from  an  excess  in  rate  of  growth  of  the  placenta  over  that  of  the 
cervix,  a  structure  which  was  not  designed  for  placental  attachment, 
and  which  is  not  fitted  to  keep  pace  with  the  placenta.  Hence  loss  of 
relation;  hence  the  placenta  shoots  beyond  its  site, and  hemorrhage  re- 
sults." I  must  confess,  however,  that  I  rather  incline  to  the  view  which 
considers  the  flow  at  this  period  due  to  the  more  rapid  development  of 
the  lower  portion  of  the  uterine  body.  The  hemorrhage  may  be  so  sud- 
den and  copious,  even  at  this  first  onset,  as  to  prove  nearly,  if  not  quite 
fatal ;  more  generally,  however,  its  first  manifestation  is  but  slight,  ceas- 
ing if  the  woman  lies  down  and  remains  quiet.  This  early  sanguineous 
flow,  when  slight  and  so  easily  checked,  is  looked  upon  by  the  patient 
as  an  accident  depending,  probably,  upon  some  strain,  exertion,  etc., 
and  after  its  cessation  is  no  more  thought  of.  In  five  or  six  days,  a 
further  detachment  of  the  placenta  is  occasioned  by  the  continued 
development  of  the  cervical  part  of  the  uterine  body,  and  a  fresh  dis- 
charge takes  place,  which  is  apt  to  be  greater  than  before ;  and  from, 
time  to  time  these  attacks  of  bleeding  occur,  increasing  in  severity 
each  time,  until,  if  the  woman  reach  her  full  term,  she  may  be  so  com- 


488  KING'S  ECLECTIC  OBSTETRICS. 

pletely  exhausted  and  prostrated  from  loss  of  blood,  as  to  be  incapable 
of  sustaining  the  loss  of  even  a  few  ounces  more.  A  woman  who  has 
not  suffered  from  bleedings  previous  to  term,  and  of  strong  constitu- 
tion, is  more  likely  to  recover,  uninjured,  from  a  placenta  prsevia  labor, 
than  one  the  reverse.  As  regards  the  hemorrhage  at  full  term,  Dr. 
Barnes  observes:  "The  mouth  of  the  womb  must  open  to  give  passage 
to  the  child.  This  opening,  which  implies  retraction  or  shortening  of 
the  Cervical  zone,  is  incompatible  with  the  preservation  of  the  adhe- 
sion of  the  placenta  within  its  scope.  In  every  other  part  of  the 
womb  there  is  an  easy  relation  between  the.  contractile  limits  of  the 
muscular  structure  and  that  of  the  cohering  placenta.  Within  the 
cervical  region  this  is  lost.  The  diminution  in  surface  of  the  uterine 
tissue  is  in  excess." 

The  circumstances  under  which  a  vaginal  examination  must  be  made 
are,  1st,  when  the  hemorrhage  is  copious  and  continued;  2d,  when  the 
patient  has  reached  full  term,  or  is  within  several  days  of  it;  and  3d, 
when  uterine  contractions  manifest  themselves,  however  slight  they 
may  be,  or  however  distant  the  intervals  between  them. 

DIAGNOSIS. — A  placental  presentation  may  be  suspected  when  the 
first  hemorrhage  occurs  suddenly  [about  the  sixth  or  seventh  month, 
and  up  to  full  term],  and  without  any  apparent  cause,  being  renewed 
every  week  or  two.  If  the  placenta  be  situated  upon  the  anterior 
part  of  the  inferior  segment  of  the  uterus,  it  will  prevent  ballottement. 
At  the  period  of  labor  placenta  prsevia  may  be  suspected  by  the  gush, 
or  increased  flooding  during  a  pain,  but  which  diminishes  in  the  inter- 
vals. When  it  becomes  necessary  to  make  an  examination  per  vagi- 
nam,  we  may  then  positively  ascertain  the  nature  of  the  case.  I  have 
just  stated  lhat  an  examination  of  this  kind  must  be  made  when 
hemorrhage  is  copious  and  continued,  and  this  observation  applies  to 
all  hemorrhages  taking  place  from  the  uterus  during  the  latter  months 
of  pregnancy.  In  these  cases  we  are  not  to  wait  for  pains,  nor  be 
governed  by  them ;  for  the  probabilities  are  that  the  uterus  has  become 
so  enfeebled  or  paralyzed  from  the  large  quantity  of  blood  discharged 
that  no  pains  will  be  felt — the  organ  is  too  weak  to  contract.  Indeed, 
the  absence  or  trifling  character  of  pains  during  these  hemorrhages  is 
a  most  positive  indication  of  the  necessity  for  interference  to  learn  the 
cause  of  the  flooding,  and  to  check  it  if  possible. 

In  making  the  vaginal  examination  it  is  immaterial  as  to  the 
position  assumed  by  the  patient,  provided  the  fingers  can  be  intro- 
duced. The  first  two  fingers  may  be  passed  within  the  vagina,  or,  if 


COMPLICATED    LABOR — PUERPERAL    HEMORRHAGE,  ETC.         489 

the  os  uteri  be  high  up  in  the  pelvis,  it  may  become  necessary  to 
introduce  the  whole  hand.  The  examination  should  be  conducted 
with  great  care,  for  a  quantity  of  coagula,  will  generally  be  found  in 
the  vagina,  the  separation  or  detachment  of  which  will  cause  a  return 
of  the  hemorrhage,  or  increase  it  in  quantity.  Neither  should  the 
finger  be  forced  within  the  os  uteri;  if  this  be  not  sufficiently  dilated 
to  permit  the  entrance  of  the  finger  without  difficulty,  it  would  be 
better  to  wait  until  the  flooding  has  caused  sufficient  dilatation  or 
dilatability. 

The  placenta  will  be  recognized  by  the  soft,  fleshy,  fibrous,  lobular 
sensation  which  it  imparts  to  the  finger,  differing  from  a  coagulum  by 
being  attached  to  the  inner  surface  of  the  lower  segment  of  the  uterine 
body,  and  by  not  being  readily  perforated  or  broken  down — a  coag- 
ulum is  loose,  can  be  removed,  and  may  be  pierced  by  the  finger  and 
destroyed  without  any  difficulty.  As  the  examination  will  produce  a 
discharge  of  blood,  the  practitioner  must  make  it  a  positive  one ;  he 
must  not  allow  himself  to  mistake  a  clot,  nor  the  cervix,  for  the  pla- 
centa. The  latter  will  have  a  thick,  spongy  feeling;  the  former  is 
movable  and  readily  broken  down,  which  is  not  the  case  with  the 
placenta.  Sometimes  the  detached  uterine  surface  of  the  placenta  will 
be  covered  by  a  thick  smooth  layer  of  coagulated  blood,  which  will 
prevent  the  finger  from  coming  into  direct  contact  with  the  placenta ; 
but  any  error  in  diagnosis  from  this  circumstance  may  always  be 
avoided  by  carefully  breaking  down  or  detaching  the  coagulum. 
Whoever  will  carefully  pass  the  point  of  his  finger  over  the  uterine 
surface  of  a  recently  expelled  placenta,  whenever  the  opportunity 
offers,  will  never  confound  a  coagulum  of  blood,  however  firm,  with 
a  placenta  inserted  upon  the  lower  segment  of  the  uterine  body. 
Repeated  examinations  in  unavoidable  hemorrhage  are  unnecessary 
and  reprehensible;  one,  or  two  at  most,  are  fully  sufficient  to  ascertain 
the  true  state  and  condition  of  the  parts,  etc. 

Having  ascertained  the  presence  of  the  placenta,  the  next  inquiry 
will  be,  whether  the  presentation  be  complete  or  partial?  If  it  be 
complete,  no  membranes  can  be  felt;  if  partial,  the  edge  of  the 
placenta  maybe  readily  detected,  together  with  the  membranes  passing 
off  from  it; — a  portion  of  it  may  be  felt  closing  a  part  of  the  inner 
os  uteri,  and  through  the  membranes  may,  probably,  be  recognized 
the  presenting  part  of  the  child.  The  finger  may  also  be  carefully 
carried  around  to  ascertain  where  the  placenta  is  free  or  detached,  in 
a  complete  presentation,  but  no  efforts  should  be  made  to  separate  it, 


490  KIXC'S  KCLKCTIC  <>I:STI-:TUICS. 

or  to  pass  the  finger  between  it  and  the  inner  surface  of  the  uterus. 
Cazeaux  gives  the  following  rules  for  determining  placenta  prrevia  in 
certain  cases:  "When  the  hemorrhage  takes  place  either  in  a  woman 
with  her  first  child,  or  at  an  early  stage  of  the  gestation,  when,  in  a 
word,  the  cervix  uteri  is  not  sufficiently  dilated  to  permit  the  intro- 
duction of  a  finger,  we  might  still  be  enabled  to  determine  the  cause 
of  the  flooding  by  the  following  signs,  namely : 

"1.  A  hemorrhage  caused  by  the  placenta's  insertion  over  the 
internal  orifice  never  occurs  before  the  end  of  the  sixth  month ;  and, 
very  frequently,  not  until  the  last  four  or  six  weeks  of  gestation. 
Beside,  it  is  highly  probable  that  the  period  at  which  the  flooding 
comes  on,  is  usually  subordinate  to  the  greater  or  less  extent  of  the 
placenta  corresponding  to  the  neck;  that,  in  cases  of  insertion,  center 
for  center,  it  is  manifested  much  sooner  than  where  only  one  of  its 
margins  is  in  opposition  with  the  orifice.  Nevertheless,  there  are 
numerous  exceptions  to  this  (as  M.  Nsee'gle  considers  it)  nearly  gen- 
eral rule;  for,  in  a  large  number  of  the  cases  of  central  insertion,  the 
hemorrhage  is  not  developed  prior  to  the  commencement  of  labor. 

"2.  It  commences  spontaneously,  without  an  appreciable  cause,  and 
without  any  precursory  phenomena;  the  woman  being  often  suddenly 
aroused  in  the  middle  of  the  night  by  the  blood  escaping  from  the 
genital  parts. 

"  3.  When  manifested  for  the  first  time,  it  is  generally  inconsiderable 
in  amount  and  soon  over ;  but,  after  having  disappeared  altogether,  it 
returns,  sometimes  in  the  course  of  a  few  hours,  at  others,  not  for 
several  days;  and,  at  each  reappearance,  the  discharge  is  a  little  more 
abundant,  and,  lasts  somewhat  longer. 

"  4.  The  cervix  uteri  (considering  the  period  of  gestation)  is  usually 
thicker,  softer,  and  more  spongy,  because  the  placenta,  by  becoming 
fixed  over  this  point,  determines  there  a  more  considerable  afflux  of 
blood. 

"  5.  If  the  labor  has  commenced,  and  the  membranes  are  still 
intact,  the  flooding  constantly  augments  during  the  uterine  contrac- 
tions, and  diminishes  in  the  intervals.  But  the  contrary  is  observed 
when  the  discharge  is  occasioned  by  a  separation  of  the  placenta 
attached  to  any  other  point;  for  then  the  womb,  by  contracting, 
obliterates  the  vessels,  either  by  a  retraction  of  its  own  proper  tissue, 
or  by  the'  compression  they  are  subjected  to  from  the  parts  inclosed 
within  its  cavity ;  but,  in  the  case  under  consideration,  the  contractions 
that  affect  the  dilatation  of  the  cervix,  destroy  the  vascular  adhesions 


COMPLICATED    LABOR PUERPERAL    HEMORRHAGE,  ETC.      491 

which  unite  it  to  the  placenta,  more  and  more,  and  thus  multiply  the 
sources  of  hemorrhage.  This  sign  is  one  of  great  value  before  the 
membranes  are  ruptured;  but,  after  the  waters  are  discharged,  the 
child's  head  presses  on  the  orifice  during  the  contraction,  and  prevents 
the  blood  from  escaping. 

"  6.  The  bag  of  waters  does  not  form  as  in  an  ordinary  labor;  for 
the  insertion  of  the  placenta  over  the  neck  closes  its  orifice,  and 
prevents  the  lower  segment  of  the  ovum  from  engaging  therein,  and 
from  being  accessible  to  the  finger. 

"  7.  Lastly ;  according  to  Dewees,  the  blood  has  a  brighter  color  at 
the  onset  of  the  hemorrhage  than  when  it  comes  from  the  fundus,  and 
coagula  never  come  away,  excepting  when  the .  discharge  has  lasted 
for  some  time,  or  is  on  the  point  of  disappearing." 

The  great  mortality  of  placenta  prsevia  to  the  mother,  may  be  due 
to  one  or  more  of  several  causes,  as,  to  the  exhaustion  from  hemor- 
rhage ;  to  inflammation  of  the  veins  or  metritis  resulting  from  the 
effects  of  the  lochia  upon  the  greatly  developed  blood-vessels  of  the 
prse-cervical  part  of  the  uterus,  or,  from  version,  should  this  have 
been  accomplished;  to  post  partum  hemorrhage;  to  rupture  of  the 
cervical  tissue  following  version ;  or,  to  the  shock  occasioned  by  this 
operation.  The  child  may  die  from  even  a  small  quantity  of  blood 
lost,  but  more  generally  from  asphyxia  arising  from  deficient  aeration 
of  its  blood. 


CHAPTER   XXXVII. 

COMPLICATED    LABOR TREATMENT    OF    PLACENTA    PRSEVIA 

SYNCOPE    FROM    HEMORRHAGE. 

TREATMENT. — The  treatment  of  cases  of  placental  presentation 
will  depend  much  upon  the  period  at  which  the  practitioner  is  called, 
as  well  as  upon  the  attending  circumstances,  and  will  also  require  upon 
his  part  promptness  of  action,  rapid  observation,  calmness,  and 
firmness.  If  called  some  weeks  previous  to  full  term,  on  the  occur- 
•reuce  of  the  commencing  floodings,  and  these  are  not  very  copious, 
the  only  measures  required  will  be  to  keep  the  patient  in  a  horizontal 


492  KING'S  ECLECTIC  OBSTETRICS. 

situation,  on  a  hard  bed  and  in  a  cool  room,  enjoining  rest  and  perfect 
quiet;  and,  as  in  all  cases  of  uterine  hemorrhage,  the  bed  should  be 
placed  so  that  the  attendants  can  easily  pass  around  it:  internally, 
cold  and  acid  drinks  may  be  exhibited,  and  some  cold  astringent 
solution  may  be  injected  into  the  vagina,  but  great  care  is  necessary, 
as  these  local  applications  are  very  apt  to  arouse  uterine  contractions. 
The  covering  should  be  light,  and  the  bowels  must  be  kept  regular. 
In  fulfilling  this  latter  indication,  care  must  be  had  not  to  effect  active 
catharsis  by  internal  agents,  nor  by  stimulating  enema,  as  these  will 
have  a  tendency  to  increase  or  cause  a  return  of  the  hemorrhage— a 
consequence  of  straining  or  tenesmus,  which  may  produce  a  removal 
of  the  coagula  which  are  covering  the  lacerated  blood-vessels.  An 
injection  of  cold  water  is  probably  the  best  agent  which  can  be  em- 
ployed to  free  the  rectum,  and  it  should  be  repeated,  according  to 
circumstances,  once  or  twice  daily,  or  every  other  day.  Xot  un fre- 
quently there  will  be  more  or  less  nervous  irritability,  generally  arising 
from  an  excited  and  alarmed  condition  of  the  mind.  The  practitioner 
should  always  endeavor  to  tranquilize  any  mental  agitation  which  may 
be  present ;  and,  to  allay  the  excited  condition  of  the  nervous  system, 
Opium,  or  a  pill  of  Opium,  or  the  administration  of  Sp.  Tr.  Pulsa- 
tilla,  may  be  found  beneficial.  The  diet  of  the  patient  must  consist ' 
of  light,  nutritious  fluids,  avoiding  all  stimulating  agents  of  whatever 
character,  and  this  should  be  persisted  in  as  long  as  may  be  deemed 
proper  or  necessary. 

The  hemorrhage  having  ceased,  it  must  be  borne  in  mind  that  it 
is  liable  to  return  at  any  moment,  and  may  prove  to  be  very  excessive 
and  serious.  Before  leaving  the  house,  therefore,  full  instructions 
should  be  given  to  the  friends  for  its  management  during  the  accouch- 
eur's absence,  as  for  instance,  the  above  measures.  He  should  likewise 
strictly  enjoin  upon  them  to  send  for  him  instantly  on  its  recurrence ; 
and  lest  he  may  not  be  readily  found,  the  services  of  another  profes- 
sional brother  should  be  secured,  in  order  that  the  female  may  not 
perish  for  want  of  proper  attention.  Beside,  these  measures  show 
that  the  practitioner  feels  a  deep  interest  for  the  welfare  of  his  patient, 
secure  her  confidence  as  well  as  that  of  her  friends,  and  add  to  his 
reputation.  As  soon  as  the  causes  of  the  hemorrhage  are  suspected, 
the  friends  of  the  patient  should  be  informed,  and  the  dangers  to 
which  she  is  exposed  fully  made  known  ;  but  on  no  account  should  the 
patient  be  notified,  lest  it  might  hasten  an  unfavorable  issue,  by  creating 
an  intense  nervous  excitability  with  powerful  mental  agitation. 


COMPLICATED    LABOR — PUERPERAL    HEMORRHAGE,    ETC.        493 

Should  the  hemorrhage  be  excessive,  and  resist  the  energetic  measures 
employed  to  check  it,  or  should  uterine  contractions,  however  feeble, 
be  experienced,  with  even  moderate  loss  of  blood,  the  practitioner 
should  apply  ligatures  to  the  inferior  extremities,  and  then  proceed  to  a 
vagina]  examination,  as  heretofore  explained.  If  the  os  uteri  be  found 
rigid,  resisting  the  introduction  of  a  finger,  no  force  whatever  must  be 
employed ;  the  os  uteri  must  be  soft  and  yielding,  in  all  cases,  before 
any  introduction  of  a  finger  or  of  the  hand  is  to  be  attempted — to  do 
otherwise  is  unpardonable.  There  may  be  cases,  where  the  hemorrhage 
is  very  copious,  with  a  rigid  and  unyielding  condition  of  the  parts 
forbidding  the  introduction  of  a  finger  for  diagnosing,  or  of  a  hand 
for  version,  in  which  this  rule  may  be  violated,  for  the  purpose  of 
endeavoring  to  afford  the  patient  the  only  chance  for  safety ;  but  it  is 
always  hazardous,  and  most  frequently  terminates  fatally.  Generally, 
however,  the  rigidity  of  the  os  uteri  will  be  speedily  overcome  by  the 
great  loss  of  blood;  if  not,  Gelsemium,  Lobelia,  or  the  compound 
tincture  of  Lobelia  and  Capsicum  may  be  given. 

In  placenta  prsevia,  the  danger  is  from  hemorrhage,  which  increases 
when  uterine  contractions  come  on,  or  when  dilatation  of  the  os  uteri 
is  progressing;  and  the  great  and  important  question  is,  when  to 
deliver  ?  The  established,  and  probably  the  safest  method  of  delivery 
is,  by  turning  and  promptly  bringing  away  the  child.  The  operation 
has  its  dangers,  but  it  is  the  best  which  can  be  pursued,  and  its  success 
will  depend  greatly  upon  the  skill  and  judgment  of  the  accoucheur. 
If  he  waits  for  the  complete  dilatation  of  the  os  uteri  before  under- 
taking the  operation,  the  exhaustion  effected  may  be  so  great  as  to 
afford  no  hope  for  the  patient's  survival,  or  she  may  perish  before  such 
dilatation  is  effected.  I  would  repeat,  therefore,  two  great  principles* 
by  which  all  medical  men  must  be  guided  in  their  management  of 
placenta  prsevia  :  1,  never  attempt  to  pass  the  hand  within  the  os  uteri 
when  it  is  in  a  rigid  condition  ;  2,  never  delay  interference  by  version 
or  otherwise,  until  full  dilatation  of  the  cervical  orifice  has  been 
accomplished. 

The  time  for  operation  has  arrived,  when  the  os  uteri,  being  soft  and 
yielding,  has  dilated  to  the  size  of  a  half  dollar,  or  sufficient  to  easily 
admit  the  introduction  of  the  points  of  the  fingers  and  thumb;  to 
wait  for  a  greater  enlargement  of  the  orifice,  would  be  to  increase  the 
hazards  to  the  patient,  because  the  hemorrhage  becomes  more  and  more 
copious  and  alarming  as  the  development  of  the  os  continues  to  ad- 
vance ;  to  interfere  sooner,  would  be  at  the  risk  of  effecting  considerable 


494  KING'S  ECLECTIC  OBSTETRICS. 

injury  to  the  os  uteri. — It  is  in  cases  of  an  insufficient  degree  of  dila- 
tability  of  the  os,  that  Barnes'  colpeurynter,  or  Molesworth's  climax 
dilator,  is  used,  to  effect  the  requisite  amount  of  dilatation,  as  well  as 
to  arrest  the  hemorrhage,  previous  to  introducing  the  hand  for  turning. 

The  requisite  amount  of  dilatation  having  been  accomplished,  the 
female  should  be  placed  upon  her  back ;  or  if  the  hemorrhage  be 
excessive,  or  she  be  very  much  exhausted,  she  must  not  be  moved, 
but  the  version  must  be  effected  while  she  is  lying  on  her  left  side. 
It  is  always  advisable  to  relieve  the  ruptured  vessels  from  blood  pre.— 
.sure,  by  ligating  both  limbs  high  up  around  the  thighs,  which  by 
retaining  the  blood  in  the  extremities,  serves  as  a  reserve  that  may  be 
again  admitted  into  the  general  circulation  as  soon  as  the  immediate 
danger  has  passed.  The  pelvic  extremity  of  the  patient  should,  if 
possible,  be  considerably  elevated  above  the  head,  so  that  the  body 
shall  lie  in  an  inclined  position,  the  head  being  the  lowest  part,  and 
this  may  readily  be  effected  by  lifting  up  the  bedstead  and  securing 
the  legs  of  one  end  on  blocks  of  sufficient  height:  this  measure  may 
preserve  her  from  a  fatal  syncope.  The  operator  must  remove  his 
«oat,  bare  his  arm,  and  having  anointed  the  arm  and  fingers,  proceed 
to  the  introduction  of  the  hand  into  the  vagina. 

Before  introducing  the  hand,  however,  it  is  of  some  importance  to 
ascertain  the  position  of  the  child;  for  should  the  wrong  hand  be 
employed  at  first,  its  removal  will  produce  an  increase  of  the  flooding, 
and  which  may  involve  fatal  consequences  before  the  other  hand  can 
be  entered.  If  the  placenta  be  only  partially  attached  over  the  inner 
os  uteri,  or  if  one  side  of  it  be  wholly  detached,  the  finger  may  be 
passed  between  the  free  end  of  the  placenta  and  the  uterus  until  it 
reaches  the  membranes,  when  the  position  may  be  ascertained  through 
these;  or  if  this  can  not  be  done,  and  the  patient  be  not  too  corpulent, 
an  external  examination  over  the  abdomen,  in  the  absence  of  pains, 
may  detect  the  globular  head  at  the  lower  portion  of  the  belly,  and  the 
curve  of  the  child's  spine  being  found  on  the  right  or  left  side,  will 
determine  its  position.  This  can  not,  however,  be  easily  ascertained 
in  all  cases,  and  the  practitioner  will  then  employ  his  left  hand,  on  the 
presumption  that  the  head  is  in  the  most  usual  position,  or  that  in 
which  the  occiput  looks  toward  the  left  acetabulum. 

"  In  every  case,  before  attempting  to  turn,  make  a  most  careful 
examination  of  the  os  uteri,  and  endeavor,  from  the  degree  of  dilata- 
tion, and  the  thinness  and  softness  of  the  orifice,  to  form  a  correct 
judgment  upon  its  dilatability  before  interfering;  for  if  your  attempt 


PRETERNATURAL    LABOR — PUERPERAL  HEMORRHAGE,  ETC.     495 

be  unsuccessful,  the  hemorrhage  will  be  renewed,  and  the  patient 
will  be  placed  in  a  worse  condition  than  she  was  before."  (Lee.) 

The  fingers  and  hand  are  to  be  slowly  and  carefully  passed  within 
the  vagina,  in  a  conical  form,  as  heretofore  explained,  and  carried 
up  to  the  os  uteri.  As  the  fingers  are  insinuated  within  the  os 
uteri,  they  should  also  gently  dilate  it,  advancing  upward  between  the 
free  or  detached  side  of  the  placenta  (which  must  be  detected  by  a 
careful  exploration,  as  already  referred  to)  and  the  inner  surface  of 
the  uterus.  If  the  placenta  be  not  sufficiently  separated  to  admit  of 
the  entrance  of  the  hand,  an  artificial  separation  must  be  cautiously 
effected,  selecting,  when  possible,  that  side  of  the  placenta  for  the 
detachment  which  is  ascertained  to  be  the  thinnest,  which  will  be  the 
nearest  to  its  edge,  and  where,  consequently,  the  uterine  blood-vessels 
will  be  the  smallest.  As  soon  as  the  fingers  have  entered  the  os  uteri, 
a  greater  or  less  discharge  of  blood  will  almost  always  follow,  but  at 
which  the  practitioner  must  not  be  alarmed ;  firmness,  self-possession, 
and  gentleness  are  required;  and  should  the  practitioner,  alarmed  at 
the  fresh  discharge,  attempt  the  withdrawal  of  his  hand  at  this  time, 
a  fatal  increase  of  it  would  very  probably  be  the  result.  As  soon  as 
the  hand  has  thoroughly  entered  the  uterine  cavity,  the  wrist  or  arm 
prevents  any  further  material  loss  of  blood,  by  compressing  the  orifices 
of  the  bleeding  vessels. 

The  hand  should  be  passed  as  high  up  between  lAie  uterus  and 
membranes  as  possible — these  should  then  be  ruptured — the  hand 
carried  within,  and  the  feet  of  the  child  be  obtained.  If  both  feet 
can  not  be  readily  found,  the  version  may  be  effected  by  one  only, 
instead  of  delaying  the  delivery  by  a  prolonged  search  for  the  other. 
The  version  should  be  carefully  effected,  but  with  as  much  expedition 
as  is  consistent  with  the  safety  of  the  child  and  patient,  and  the  limbs 
should  be  brought  down  into  the  vagina  until  the  hips  or  body  of 
the  infant  is  in  contact  with  the  uterine  cervix ;  and  'this  is  to  be 
performed,  not  only  to  facilitate  delivery  >  but  tljat  the  compression 
of  the  bleeding  vessels  by  the  fetal  pelvic  region  may  check  any 
excessive  hemorrhage.  After  the  hand  has  been  introduced  within  the 
uterus,  and  the  placenta  has  been  detached,  if  the  practitioner  with- 
draws it  without  effecting  version,  fatal  hemorrhage  may  immediately 
ensue.  Therefore,  in  all  instances,  where  it  is  desired  to  detach  the 
placenta  wholly  or  partially,  without  turning  the  child,  the  whole 
hand,  or  even  the  greater  part  of  it,  should  never  be  passed  within 
the  uterine  cavity. 


496  KING'S  ECLECTIC  OBSTETRICS. 

A  sudden  removal  of  the  contents  of  the  uterus  might  give  rise  to- 
inertia  of  the  organ  and  fatal  flooding;  therefore,  unless  the  copious- 
ness of  the  discharge  requires  the  immediate  delivery  of  the  child, 
this  must  not  be  eifected.  The  uterus  must  not  be  emptied  too 
rapidly.  And  in  every  case  of  hemorrhage  from  placental  presenta- 
tion, as  soon  as  the  version  is  completed,  a  full  dose  of  Ergot,  should 
be  administered,  not  so  much  for  the  purpose  of  aiding  in  the  expulsion 
of  the  child,  as  to  secure  permanent  contractions  of  the  uterus  sub- 
sequently. For  it  must  be  remembered,  that  the  life  of  the  patient 
depends  entirely  upon  perfect  and  persistent  uterine  contractions. 
Beside  the  Ergot,  frictions,  and  other  means  which  have  been  hereto- 
fore spoken  of,  to  arouse  or  preserve  the  action  of  the  uterus,  may  be 
employed.  The  bandage  should  never  be  omitted. 

Some  writers  recommend  the  perforation  of  the  placenta  itself, 
but  this  is  a  very  difficult  operation,  and  when  accomplished,  may 
effect  the  death  of  the  child  and  mother  from  augmented  hemorrhage 
occasioned  by  the  certain  rupture  of  large  blood-vessels,  or  from  a 
delay  or  difficulty  in  the  passage  of  the  child  through  the  insufficient 
opening  made  by  the  hand.  It  should  never  be  attempted. 

The  practitioner  may,  however,  be  called  to  a  case  of  this  complica- 
tion, where  the  hemorrhage  is  copious  and  frightful,  before  the  os 
uteri  is  sufficiently  dilated,  and  in  which  delay  would  be  death.  If 
the  os  uteri  be  found  rigid  and  unyielding,  no  attempts  at  forcibly 
entering  it  with  the  hand  are  justifiable — such  attempts  are  always 
dangerous.  The  only  course  to  be  pursued  is  to  procure,  if  possible, 
a  diminution  of  the  discharge,  until  the  os  uteri  is  in  a  more  favorable 
state.  For  this  purpose,  ligatures  should  be  applied  to  the  extremities, 
the  patient  should  be  kept  quiet  in  a  recumbent  position  with  the  hips 
slightly  elevated.  Cold,  acidulated,  or  astringent  draughts  should  be 
administered  internally,  as  well  as  heart -sedatives,  and  the  vagina 
may  likewise  be  plugged  with  a  tampon  wet  with  a  solution  of  Alum, 
or  dilute  Perchloride  of  Iron,  and  which  will  occasionally  be  found 
useful.  In  the  early  part  of  this  work  I  stated  that  the  tampon  was 
not  to  be  used  in  hemorrhages  from  the  uterus,  occurring  after  the 
fifth  or  sixth  month.  The  present  instance  may,  however,  be  con- 
sidered an  exception,  as  there  can  not  be  a  concealed  hemorrhage  to 
any  great  extent  so  long  as  the  membranes  remain  entire,  and  the 
cavity  of  the  uterus  is  not  in  a  condition  to  receive  a  large  amount  of 
blood,  except  such  as  may  pass  between  the  inferior  part  of  the  mem- 
branes and  the  cervix,  unless,  indeed,  the  organ  be  in  a  very  lax 


COMPLICATED    LABOR — PUERPERAL    HEMORRHAGE,    ETC.         497 

condition  with  great  prostration  of  the  vital  forces.  Beside,  the  use 
of  the  tampon  does  not  dispense  with  the  careful  watching  of  the 
patient,  observing  the  features,  the  pulse,  etc.  When  no  unfavorable 
symptoms  follow  the  employment  of  the  tampon,  its  removal  will  be 
indicated  by  the  strength  and  frequency  of  the  pains.  I  do  not 
recommend  the  use  of  the  tampon  in  partial  placental  presentation, 
but  only  in  those  instances  where  the  membranes  can  not  be  reached 
on  account  of  the  internal  orifice  being  wholly  occupied  by  the  after- 
birth. In  many  instances,  notwithstanding  the  use  of  all  the  above 
measures,  the  flooding  will  continue  unrestrained;  it  then  become^ 
necessary  to  hasten  the  delivery  by  all  possible  means.  Should  the 
rigidity  be  subdued  by  the  great  relaxation  produced  by  the  excessive 
loss  of  blood,  or  by  the  means  employed  for  this  purpose,  then  the 
following  course  may  be  attempted  : 

But  if,  instead  of  a  rigid  condition  of  the  os  uteri,  a  soft,  dilatable 
one  be  found,  however  small  the  opening,  the  hemorrhage  being,  as 
above  remarked,  frightful,  the  fingers  may  be  carefully  entered  within 
the  orifice  one  by  one,  gradually  dilating  it  as  they  proceed,  until  the 
hand  can  be  so  far  introduced  as  to  effect  the  version.  This  is  not  a 
desirable  method,  neither  is  it  of  easy  performance,  and  being  always, 
more  or  less  hazardous,  should  never  be  undertaken  except  under 
imperative  circumstances;  it  then  becomes  the  best  and  only  course 
left  us,  and  should  be  employed  with  all  the  precautions  which  a 
knowledge  of  its  disadvantages  and  dangers  would  suggest.  In  these 
frightful  cases  a  delay  may  be  fraught  with  fatal  results.  "As  a 
principle,  delivery  had  better  be  had  recourse  to  an  hour  too  soon 
than  an  hour  too  late."  "  It  is  the  loss  of  the  last  half  pint  of  blood 
that  kills  the  patient."  "  Sometimes,  when  in  these  cases,  it  is  impos- 
sible to  pass  the  whole  hand  through  the  os  uteri,  the  delivery  may  be 
safely  accomplished  by  merely  passing  one  hand  into  the  vagina,  and 
afterward  the  fore  and  middle  fingers  between  the  uterus  and  detached 
portion  of  the  placenta,  grasping  with  them  the  feet,  which  are 
generally  situated  near  the  os  uteri,  and  drawing  down  the  inferior 
extremities  into  the  vagina  and  delivering."  (Lee.)  \ 

In  these  cases,  the  physician  should  always  have  his  forceps  at  hand, 
in  order  to  extract  the  head,  should  any  delay  or  difficulty  occur  in  its 
delivery. 

I  will  observe  here  that  I  have  known  of  three'  cases  of  placenta 
prsevia,  in  which  the  delivery  was  successfully  and  safely  effected,  by 
the  accoucheur  carefully  inserting  a  finger  within  the  os  uteri  and 
32 


498  KING'S  ECLECTIC  OBSTETRICS. 

detaching  enough  of  the  placenta  to  enable  him  to  elevate  the  child 
and  pass  the  detached  portion  upwards  along  the  side  of  the  head. 
The  head  descended  into  the  brim,  hemorrhage  ceased,  and  the  placenta 
was  safely  delivered  after  the  child.  In  dangerous  cases,  with  exhaus- 
tion that  would  imperil  the  patient's  life  from  the  shock  of  turning, 
also  where  the  child  is  dead,  it  has  been  advised  to  detach  the  placenta 
completely  and  then  leave  the  case  to  nature.  It  is  stated  that  the 
hemorrhage  ceases  after  the  detachment,  and  the  chances  for  both 
mother  and  child  are  much  more  favorable  than  by  any  other  method. 

When  the  placental  presentation  is  PARTIAL  or  INCOMPLETE, 
that  is,  when  its  edge  extends  only  to  the  margin  of  the  inner  os  uteri, 
or  perhaps,  covering  one-third,  one-half,  or  any  other  proportion  of 
this  orifice,  the  remaining  part  presenting  the  membranes,  symptoms 
of  a  character  similar  to  those  in  complete  placenta  prsevia  will  be  met 
with,  requiring  a  somewhat  analogous  treatment.  This  form  of  pla- 
cental presentation  is  of.  more  frequent  occurrence  than  the  complete. 
When  labor  is  on,  and  the  hemorrhage  is  profuse,  the  best  course  is, 
to  rupture  the  membranes,  without  regard  to  the  extent  of  dilatation 
of  the  os  uteri,  which,  by  allowing  the  liquor  amnii  to  escape,  will 
permit  the  head  or  breech,  as  the  presenting  part  may  be,  to  descend 
and  compress  the  bleeding  orifices,  thereby  checking  or  diminishing 
the  flooding.  The  head  having  descended,  the  forceps  may  be 
applied,  if  necessary,  and  the  delivery  hastily  terminated.  At  the 
same  time,  the  tincture  of  Gelsemium  may  be  exhibited  to  forward 
the  dilatation  of  the  os  uteri,  while  the  bandage  may  be  applied,  and 
othei»  means  used  to  cause  vigorous  uterine  contractions;-  and  at  the 
proper  period  Ergot  may  be  given  to  facilitate  the  expulsive  process, 
but  this  drug  must  not  be  administered  when  the  natural  efforts  are 
alUsufficiont,  except  it  be  for  the  purpose  of  securing  permanent 
contractions  after  the  delivery. 

Should  this  course  fail,  the  hemorrhage  continuing,  or,  should 
there  be  exhaustion  of  the  system,  from  the  amount  of  blood  lo-t, 
the  better  plan  will  be  to  rupture  the  membranes  and  turn;  beinir 
governed  by  the  rules  already  laid  down  for  version  in  complrti- 
placental  presentation. 

In  case  the  liquor  amnii  has  been  discharged,  and  version  is  desira- 
ble, the  hand  will  find  but  little  difficulty  in  entering  within  the 
uterine  cavity,  because  the  excessiye  flooding  will,  very  likely,  effect 
a  lax,  yielding  condition  of  the  parietes  of  the  organ  ;  this  is  unlike 


COMPLICATED    LABOR — PUERPERAL   HEMORRHAGE,  ETC.         499 

preternatural  presentations,  in  which  a  loss  of  the  amniotic  fluid  is 
followed  by  energetic  contractions,  rendering  it  almost  impossible  to 
introduce  the  hand  for  the  operation  of  turning.  Beside,  in  placenta 
prsevia,  should  the  contractions  be  sufficiently  vigorous  to  advance  the 
head,  the  pressure  made  by  it  on  the  orifices  of  the  vessels  will  dimin- 
ish the  flow,  and  there  will  then  be  no  necessity  for  the  introduction 
of  the  hand,  as  the  delivery  will  be  effected  by  the  natural  powers, 
except  indeed,  the  pelvis  be  malformed,  or  the  soft  parts  be  rigid  and 
unyielding. 

In  preternatural  presentations  of  the  fetus,  with  placenta  prsevia,  or 
in  a  small  or  deformed  pelvis,  it  will  be  proper  to  turn,  provided  the 
hand  can  be  introduced  for  the  purpose — and,  in  the  latter  instance, 
when  the  head  can  not  descend,  or  pass  through  the  cavity  and  inferior 
strait,  it  will  require  the  use  of  the  perforator  to  terminate  delivery. 

A  brief  synopsis  of  the  treatment  that  has  been  advised  in  placenta 
prsevia  may  prove  useful :  When  copious  hemorrhage  is  present  at  full 
term,  the  woman's  strength  good ;  the  os  uteri  dilatable ;  the  pelvis 
normal;  the  child  alive;  if  the  patient  be  multiparous,  version,  or  the 
Jorceps,  without  delay;  if  primiparous,  complete  separation  of  placenta, 
>or  version.  If  the  child  be  dead ;  os  uteri  rigid;  patient  exhausted; 
pelvis  abnormal ;  previous  to  full  term ;  partially  or  wholly  detach 
placenta,  and,  if  necessary,  apply  Perchloride  of  Iron  or  other  styptic. 
If  the  patient  be  exhausted  give  stimulants.  It  is  in  cases  of  rigidity, 
.and  where  the  os  is  not  sufficiently  dilated,  that  the  colpeurynter,  or 
Molesworth's  climax  dilator,  may  be  used  to  overcome  the  rigidity,  or 
to  soften  and  dilate  the  os,  and  check  the  hemorrhage.  In  the  absence 
of  these,*  introduce  the  speculum  and  plug  up  the  vagina  with  absorb- 
ent cotton,  soft  sponge,  lint,  tow,  strips  of  old  muslin,  or  such  non- 
irritating  material  as  heretofore  recommended  in  using  a  tampon. 
The  first  portion  should  be  thoroughly  moistened  with  a  solution  of 
Alum,  Tannic  Acid,  or  Perchloride  of  Iron.  The  tampon  should 
So  kept  in  place  or  renewed  until  the  condition  of  the  parts  are  suffi- 
ciently dilated  to  permit  the  accoucheur  to  deliver.  It  ii  advised, 
\vlien  it  becomes  necessary  to  turn  before  the  position  has  been  ascer- 
tained, that  the  practitioner  proceed  on  the  supposition  that  the 
child's  head  is  in  the  left  occipito-anterior  position,  and  that,  conse- 
quently, he  employs  the  left  hand,  passing  it  up,  in  partial  placental 
prsevia,  through  that  portion  of  the  membranes  that  can  be  felt;  in 
complete,  pass  it  between  the  placenta  and  uterine  surface,  detaching 
the  cake  as  ilr.)  h:ind  is  carried  along-. 


500  KING'S  ECLECTIC  OISSTKTIMCS. 

The  treatment  after  delivery  will  be  in  accordance  with  the. rules 
hereafter  given,  endeavoring  to  produce  persistent  uterine  contractions 
which  will  prevent  a  return  of  hemorrhage — also  to  sustain  strength, 
and  allay  the  irritable  condition  of  the  system. 

In  hemorrhage  from  placental  presentation,  as  well  as  in  all  puer- 
peral hemorrhages,  there  is  one  very  important  symptom  to  which  the 
attention  must  be  especially  directed — I  mean  SYNCOPE,  or  a  state 
approaching  to  it.  When  the  female  has  lost  a  large  amount  of  blood 
the  practitioner  will  probably  find  her  pale,  cold,  and  gasping,  the 
uterus  torpid  and  exceedingly  flabby,  the  pulse  nearly  gone,  with  a 
fluttering  of  the  heart,  and  a  greater  or  less  degree  of  insensibility. 
Upon  an  examination  the  flow  of  blood  will  be  found  suspended;  but 
in  making  the  examination,  when  the  above  symptoms  are  present,  the 
greatest  care  must  be  had  not  to  disturb  the  patient,  nor  to  pass  the 
finger  into  the  vagina — it  must  be  ascertained  from  the  appearance  of 
fresh  cloths  applied  to  the  external  parts.  In  such  cases,  the  patient 
must  not  be  moved — a  change  of  position  frequently  results  fatally  ; 
neither  must  any  manual  operations  be  performed  for  the  purpose  of 
emptying  the  uterus  or  otherwise  endeavoring  to  promote  its  contrac- 
tions. Should  the  patient  be  not  altogether  insensible,  she  will  mani- 
fest an  intolerable  restlessness  of  disposition,  a  desire  to  change  her 
posture,  which,  if  acceded  to,  will  occasion  sudden  death.  If  the  hand 
be  introduced  within  the  uterus,  for  any  purpose  whatever,  a  disturb- 
ance of  the  coagula  will  immediately  renew  the  flooding,  and  sudden 
death  will  almost  certainly  take  place.  It  has  been  observed  that  when 
the  female  lies  on  her  left  side,  the  tendency  to  syncope  is  very  much 
lessened. 

Instead,  therefore,  of  rendering  useless  attempts  at  any  manual 
operations,  the  practitioner  should  keep  his  patient  with  her  hips 
elevated  somewhat  higher  than  her  head,  and  then  employ  meas- 
ures to  rouse  the  sinking  system,  and  sustain  her  strength,  until 
she  has  so  far  recovered  that  attempts  may  be  made  to  empty  the 
uterine  cavity,  if  necessary.  And,  to  accomplish  this  indication, 
stimulants  must  be  given.  Brandy,  Rum,  Ether,  Ammonia,  or 
other  stimulants  may  be  administered.  And  if  these  be  conjoined 
with  Sulphate  of  Quinia,  the  results  will  generally  follow  more 
promptly  and  continue  more  persistently.  If  the  spirituous  prep- 
arations be  used,  it  is  better  to  give  them  undiluted,  if  the  patient 
can  bear  it,  because  it  will  require  a  less  amount  of  fluid  to  be 


COMPLICATED  LABOR — SYNCOPE  FROM  HEMORRHAGE,  ETC.     501 

thrown  into  the  stomach,  and  this  organ  will  be  less  likely  to  reject 
it.  These  stimulants  must  be  persevered  in,  until  they  have  exerted 
a  decided,  but  not  too  highly  stimulating,  influence  upon  the  system, 
as  manifested  by  an  increase  of  the  pulse,  an  augmentation  of  the 
temperature  of  the  extremities,  a  reddening  of  the  lips,  and  a  return 
to  consciousness;  and  when  these  symptoms  present,  the  further 
exhibition  of  stimuli  may  be  dispensed  with.  In  cases  of  this  char- 
acter the  stomach  will  be  nearly  as  insensible  as  the  rest  of  the  system, 
and  will  not  be  so  readily  acted  on  by  these  cordials  as  when  in  a 
more  healthy  and  vigorous  condition ;  one  or  two  fluid  ounces  of  un- 
diluted Brandy  may  be  given  at  a  dose,  and  repeated  every  five,  ten, 
or  twenty  minutes,  according  to  the  degree  of  depression  of  the  vital 
powers.  In  extreme  prostration  it  may  be  necessary  to  administer 
stimulants  hypodermically.  If  too  long  continued,  the  stimulation  of 
the  vital  powers  by  spirituous  liquids  may  be  followed  by  a  greater 
and  more  dangerous  prostration  of  both  mind  and  body;  on  which 
account  it  is  decidedly  better,  after  their  influence  has  become  man- 
ifested, to  omit  them,  and  give  other  stimulants,  as  Carbonate  of 
Ammonia;  a  mixture  of  Sulphate  of  Quinia  and  Capsicum;  Cinna- 
mon, etc.;  by  this  means  they  can,  if  required,  be -again  resorted  to 
with  much  better  effect.  I  succeeded  in  rallying  one  case,  seemingly 
from  the  throes  of  death,  by  the  use  of  the  hundredth  of  a  grain  of 
Digitalin,  administered  hypodermically,  and  repeated  in  twenty  min- 
utes; after  the  second  do'se  the  patient  had  sufficiently  reacted  to 
partake  of  alcoholic  stimulants. 

But,  not  unfrequently,  witli  the  fainting  or  syncope,  there  may  be 
a  continued  flow  of  blood;  this  is  a  very  serious  condition,  especially 
if  the  female  be  sinking  rapidly.  Under  these  circumstances,  the 
object  will  be  to  suppress,  if  possible,  the  hemorrhage,  and  for  which 
it  is  difficult  to  give  any  specific  rule.  The  rupture  of  the  membranes, 
followed  by  a  discharge  of  the  liquor  amnii,  or  the  removal  of  the 
fetus,  or  the  delivery  of  the  placenta,  may  either  of  them  be  followed 
by  contractions  of  the  uterus,  and  a  consequent  suppression  of  the 
flooding,  and  thereby  prove  the  safest  course  to  adopt;  while,  on  the 
ether  hand,  and  particularly  if  the  female  be  much  exhausted  by  the 
drain  from  the  system,  and  the  syncope  be  long  continued  or  extreme, 
the  wiser  course  will  probably  be  to  refrain  from  all  operations,  trust- 
ing to  the  natural  resources,  aided  by  the  general  external  and  in- 
ternal measures  usually  employed  in  severe  hemorrhages,  without  any 
disturbance  of  the  patient's  position. 


502  KING'S  ECLECTIC  OBSTETRICS. 


CHAPTER   XXXVIII. 

COMPLICATED     LABOR ACCIDENTAL     HEMORH  1 1  ACE CONCEALED 

HEMORRHAGE HEMORRHAGE    AFTER    PLACENTAL    DELIVERY 

—EFFECTS    OF    LOSS    OF    BLOOD. 

THE  SECOND  FORM  of  puerperal  hemorrhage  is  that  which 
occurs  in  the  latter  weeks  of  pregnancy,  as  well  as  during  labor,  in 
which  the  placenta  is  not  attached  over  the  inner  os  uteri,  but  to  some 
other  portion  of  the  uterine  parietes.  It  includes  hemorrhages  at  any 
stage  of  labor  previous  to  the  birth  of  the  child  ;  as,  before  the  rupture 
of  the  membranes,  after  the  evacuation  of  the  amniotic  fluid,  after  the 
expulsion  of  the  head,  and  during  the  presence  of  the  shoulders  in  the 
pelvic  cavity.  It  has  been  termed  accidental  or  concealed  hemorrhage. 

The  immediate  cause  of  this  kind  of  hemorrhage  is  the  separation 
of  a  part  or  the  whole  of  the  placenta  from  the  uterus,  and  which  may 
be  the  result  of  severe  or  sudden  shocks,  as  blows,  falls,  undue  pressure 
over  the  hypogastrium,  mental  agitation,  excessive  laughter,  straining 
at  stool,  railroad  traveling,  etc. ;  more  commonly,  it  is  owing  to  some 
internal  cause,  as  shortness  of  the  umbilical  cord  from  surrounding 
the  child's  neck  or  body,  abnormal  condition  of  the  placenta,  etc. 
Occasionally  it  takes  place  without  any  discoverable  cause.  A  dis- 
charge of  blood  may  also  take  place  from  rupture  of  one  or  more 
vessels  of  the  umbilical  cord,  but  this  is  of  rare  occurrence. 

More  commonly,  accidental  hemorrhage  is  not  observed  until  after 
the  commencement  of  labor ;  but  it  frequently  happens  that  there  may 
be  one  or  more  discharges  of  blood  for  some  weeks  previously.  These 
early  discharges  may  determine  the  character  of  the  difficulty,  and  its 
disconnection  with  placenta  prsevia,  by  observing  that,  in  almost  all 
instances,  they  have  been  preceded  by  some  sudden  or  unusual  shock,, 
while  in  placental  presentation,  the  flooding  occurs  suddenly  without 
any  previous  excitement  or  injury,  and  frequently  happens  during 
sleep. 

The  hemorrhage  may  immediately  manifest  itself  upon  the  presence 
of  the  exciting  cause,  or  it  may  not  appear  for  a  greater  or  less  time 
subsequently,  being  preceded  by  uneasy  sensations,  and  an  aching  and 
dull  pain  in  the  back  and  abdomen.  Its  quantity  may  vary  from  a  few 
ounces  to  an  amount  sufficient  to  speedily  destroy  life,  being  generally 
proportioned  to  the  extent  of  surface  exposed  ;  but,  very  frequently, 
fatal  flooding  occurs  where  the  exposed  space  scarcely  exceeds  an  inch. 


COMPLICATED    LABOR — CONCEALED    HEMORRHAGE,    ETC.         503 

square.  And  it  may,  or  may  not,  be  accompanied  by  labor-pains, 
depending,  however,  upon  the  period  of  gestation  when  it  happens; 
but  should  this  be  at  full  term,  and  the  pains  present,  the  hemorrhage 
will  be  checked  while  they  are  on,  but  will  return  again  during  the 
intervals  between  them. 

It  must  be  recollected  that,  there  may  be  a  very  serious  hemorrhage 
going  on  internally,  without  the  appearance  of  a  single  drop  of  blood 
externally,  and  if  the  practitioner  is  not  aware  of  this  fact  he  may  lose 
his  patient,  even  before  he  suspects  the  true  state  of  her  case.  There- 
fore, we  are  never  to  judge  of  the  condition  of  the  patient  by  the 
amount  of  blood  which  has  been  discharged  externally — and  this  rule 
will  hold  good  in  all  puerperal  hemorrhages — but,  by  the  general 
symptoms  of  exhaustion,  as  rigors,  weight  or  sudden  distension  of  the 
uterus,  faintness,  nausea,  vomiting,  coldness  of  the  extremities,  feeble 
but  rapid  pulse,  hurried  breathing,  paleness  of  countenance,  sighing 
and  yawning,  and,  if  the  discharge  be  not  arrested,  intolerable  rest- 
lessness, dimness  of  sight,  ringing  in  the  ears,  hiccough,  and  death 
preceded  by  syncope  or  convulsions ;  and  these  symptoms  may  be 
present  when  the  vaginal  discharge  is  so  slight  as  hardly  to  attract 
any  notice.  Usually,  when  syncope  occurs,  it  is  followed  by  a  suspen- 
sion of  the  hemorrhage,  which  re-appears  as  often  as  the  patient  becomes 
conscious,  and  thus  syncope  and  hemorrhage  may  continue  to  alternate 
with  each  other,  until  the  fatal  moment  arrives. 

DIAGNOSIS. — In  all  cases  of  puerperal  hemorrhage  occurring 
previous  to  the  birth  of  the  child,  it  is  an  imperative  duty  on  the  part 
of  the  medical  attendant  to  institute  a  careful  examination  per  vaginam,. 
in  order  to  ascertain  whether  or  not  the  placenta  be  completely  or 
partially  over  the  inner  os  uteri.  Of  course,  if  the  hemorrhage  should 
be  present  previous  to  the  commencement  of  labor,  the  os  uteri  will 
be  found  undilated,  and  no  information  can  be  had  by  the  examina- 
tion. If,  however,  it  happens  at  term,  and  especially  if  pains  are,  or 
have  been  recognized,  the  cervix  will  be  found  relaxed  and  yielding,  a 
result  caused  by  the  hemorrhage,  and  we  can  usually  introduce  the 
finger  within  the  os  uteri  so  as  to  detect  either  the  membranes  or  the 
placenta ;  this  must  always  be  done,  even  if  the  whole  hand  has  to  be 
passed  into  the  vagina,  in  order  to  make  a  thorough  and  satisfactory 
diagnosis,  in  all  cases  where  the  least  doubt  exists  In  the  flooding 
under  consideration,  the  finger  will  not  find  the  placenta  at  any  part 
of  the  os  internum  uteri ;  this  latter  will  be  free,  its  marginal  circum- 
ference will  be  of  the  same  thickness  all  round,  and  the  membranes 


504  KIN<i's    KCLKCTIC    olJSTKTIJirs. 

only  will  be  felt  in  contact  with  the  point  of  the  finger  when  this  is 
advanced  upward. 

Beside  this  investigation,  which  should,  as  before  remarked,  always 
be  made,  there  are  several  signs  which  will  materially  assist  in  the 
diagnosis.  Thus,  in  accidental  hemorrhage,  some  previous  excitement 
or  shock  will  generally  have  occurred ;  if  the  pains  are  on,  the  hemor- 
rhage is  arrested  by  them,  but  recurs  during  the  intervals — in  unavoid- 
able hemorrhage  the  flow  has  presented  itself  at  different  periods  during 
the  last  weeks  of  gestation,  and  when  labor  is  on  the  discharge  stops 
or  slightly  continues  during  the  intervals,  and  is  augmented  by  the 
pains. 

TREATMENT.— The  treatment  of  accidental  hemorrhage  will 
vary  according  to  the  quantity  of  blood  lost,  the  period  at  which  it 
occurs,  and  the  condition  of  the  os  uteri.  When  it  occurs  previous  to 
full  term,  labor-pains  being  absent,  and  no  tendency  to  dilatation  on 
the  part  of  the  os  uteri,  the  hemorrhage  not  being  so  profuse  as  to 
impair  the  constitutional  powers,  we  should  endeavor  by  all  means  to 
stop  it,  and  prevent  if  possible,  its  return. 

The  patient  should  be  kept  in  a  horizontal  position,  on  a  cool,  hard 
bed;  her  covering  should  be  light,  and  the  surrounding  temperature 
of  the  room  should  be  considerably  reduced.  Cold  water  only  should 
be  allowed,  or  ice;  or  the  water  may  be  acidulated  with  mineral  acids, 
which  exert  no  injurious  influence  and  are  usually  acceptable.  Injec- 
tions of  cold  water,  and  cold  applications  over  the  external  organs 
will  frequently  prove  advantageous,  but  these  should  not  be  used 
when  the  system  has  become  excessively  depressed.  The  plug  or 
tampon,  is  advised  by  some  writers,  but  I  consider  its  use  contra- 
indicated  after  the  seventh  month,  from  the  fact  that  an  external 
flooding  may  be  changed  into  an  internal  one.  The  patient  must  not 
be  allowed  to  get  up  for  any  purpose  whatever,  and  in  the  alvine 
evacuations,  especially  to  lessen  straining  efforts,  it  will  be  better  to 
aid  by  rectal  enemata. 

Should  the  flooding  be  very  excessive,  some  of  the  means  hereafter 
named,  under  the  treatment  of  Hemorrhage  after  the  delivery  of  the 
placenta,  may  be  employed,  as,  ligating  the  limbs,  tincture  of  Cinna- 
mon, or  its  combinations,  oil  of  Erigeron,  Gallic  acid,  etc. 

When,  notwithstanding  all  our  efforts  to  check  the  discharge,  it  still 
continues,  we  can  not  expect  that  pregnancy  will  persist  to  the  full 
period,  and  the  only  course  that  can  be  pursued  to  permanently  arrest 
the  hemorrhage  and  lessen  the  dangers  to  the  female,  will  be  to  effect 


COMPLICATED    LABOR-^CONCEALED    HEMORRHAGE,    ETC.         505 

an  evacuation  of  the  uterine  contents.  The  palliative  measures  will 
now  be  of  no  avail. 

The  proper  course,  then,  will  be  to  rupture  the  membranes,  and 
favor  the  escape  of  the  amniotic  liquor,  by  holding  up  the  child's 
head ;  the  contractions  of  the  uterus  may  be  excited  by  the  application 
of  the  bandage,  by  gentle  pressure  made  around  the  os  uteri  with  one 
or  two  fingers,  and  Ergot  and  stimulants  may  be  advantageously 
exhibited.  In  these  cases,  the  os  uteri  will  most  commonly  be  found 
soft  and  dilatable,  but  should  it  be  rigid  and  undilated,  the  rupturing 
of  the  membranes  should  not  be  attempted  until  this  condition  is 
overcome,  and  which  may  be  readily  accomplished  by  the  tincture  of 
Gelseminum,  tincture  of  Lobelia,  or  other  means  heretofore  explained. 

The  discharge  of  the  waters,  and  the  employment  of  the  measures 
named,  will,  in  the  majority  of  cases,  cause  the  uterus  to  contract  and 
speedily  evacuate  its  contents,  and  which  action  is  almost  invariably 
accompanied  with  a  cessation  of  the  hemorrhage.  True,  the  life  of 
the  child  may  be  endangered,  but  this  is  never  to  be  taken  into 
account  when  the  mother's  life  is  at  stake. 

I  am  aware  that  several  writers  have  objected  to  rupturing  the 
membranes  in  these  instances  of  flooding,  but  their  objections  appear 
to  me  very  insufficient,  and  the  testimony  of  many  eminent  accouch- 
eurs, together  with  my  own  experience,  justifies  me  in  strongly 
recommending  this  method,  instead  of  immediate  delivery  by  turning; 
the  hand  should  in  no  case  be  passed  into  the  uterine  cavity,  unless 
the  safety  of  the  female  imperatively  demands  it;  and  it  must  be  borne 
in  mind,  that  in  cases  of  uterine  hemorrhage,  where  the  membranes 
are  felt  at  the  mouth  of  the  uterus,  turning  is  very  seldom  required 
though  it  is  always  necessary  in  complete  placenta!  presentation. 
Sometimes,  after  the  membranes  have  been  ruptured  and  the  above 
means  used  to  arouse  uterine  action,  nothing  will  be  accomplished, 
the^hemorrhage  will  continue,  and  the  treatment  will  fail  to  bring 
about  the  desired  contractions;  this,  however,  is  not  apt  to  occur, 
unless  the  attendant  has  too  long  delayed  the  operation,  or,  where  the 
whole  or  nearly  the  whole  of  the  placenta  has  become  detached,  and 
an  excessive  internal  hemorrhage  has  consequently  ensued.  In  these 
cases  of  failure  it  will  become  necessary  to  effect  the  delivery  by 
turning,  the  employment  of  the  forceps,  or  the  perforator,  as  the 
exigencies  of  the  case  may  demand.  When  a  preternatural  presenta- 
tion is  ascertained  in  these  cases  of  hemorrhage,  it  then  always  becomes 
necessary  to  effect  a  version  as  speedily  as  possible,  but  not  before  the 
•os  uteri  is  in  a  proper  state,  leaving  the  subsequent  delivery  to  the 


506  KING'S  KCLKCTK    OBSTETRICS. 

natural  powers  when  these  are  efficient.  When  the  hemorrhage  has 
occasioned  great  exhaustion  of  the  system  with  syncope,  the  discharge 
being  suspended,  as  heretofore  observed,  the  practitioner  must  be 
extremely  cautious  how  he  attempts,  or  proceeds  in,  his  manual 
operations. 

Should  there  be  any  delay  in  the  delivery  of  the  placenta,  it  is 
generally  better,  in  cases  where  the  hemorrhage  has  been  profuse,  to 
extract  it,  in  order  to  secure  permanent  contraction  of  the  uterus  and 
thereby  lessen  any  tendency  to  a  continuation  of  the  flow,  and  every 
means  and  care  must  be  employed  to  guard,  not  only  against  a  return 
of  the  flooding,  but  also  against  an  attack  of  inflammation.  After  the 
delivery,  the  female  should  be  managed  as  hereafter  advised. 

The  THIRD  DIVISION  of  puerperal  uterine  hemorrhage,  is  that 
which  occurs  after  the  delivery  of  the  child,  but  before  the  expulsion 
of  the  placenta ;  it  is  frequently  met  with  in  practice,  and  usually 
comes  on  suddenly  and  in  excessive  quantity,  greatly  alarming  the 
patient  and  her  friends.  The  cause  of  this  flooding  is,  as  in  the  pre- 
vious ones,  a  more  or  less  complete  detachment  of  the  placenta  from  the 
uterine  walls,  with  inertia  or  inefficient  action  of  the  uterus.  It  may 
occur  in  instances  where  previous  pains  were  feeble  and  with  long 
intervals,  as  well  as  in  cases  where  the  labor  had  thus  far  been  prompt 
and  energetic ;  and  it  is  frequently  manifested  even  when  the  preceding 
stages  of  labor  had  been  most  prudently  and  skillfully  managed.  The 
recommendation,  heretofore  given,  that  after  the  birth  of  the  child  the 
accoucheur  should  ascertain  whether  the  uterus  is  contracted  or  not,  by 
placing  his  hand  upon  the  abdomen  of  his  patient  and  feeling  through 
its  parietes  for  that  organ,  is  one  which  should  never  be  omitted,  a 
rigid  observance  of  this  rule  will  keep  him  thoroughly  informed  :i> 
to  the  condition  of  the  gestating  organ,  so  that  he  can  always  be  ready 
for  prompt  measures  whenever  required. 

In  these  instances  of  hemorrhage,  shortly  after  the  birth  of  the 
child,  or,  perhaps,  immediately  succeeding  it,  a  profuse  quantity  of 
blood  is  suddenly  and  rapidly  discharged,  and  the  first  indications 
which  the  practitioner  receives  of  the  danger,  are  the  pallid  coun- 
tenance, and  the  rapid  and  feeble  pulse  of  his  patient,  with  syncope, 
or  a  state  approaching  to  it.  On  placing  his  hand  upon  the  abdomen, 
the  womb  will  be  felt  soft  and  flabby,  and  perhaps,  somewhat  enlarged  ; 
in  a  state  of  contraction  it  always  offers  a  firm,  hard  resistance  when 
pressed  upon.  The  female  soon  becomes  utterly  unconscious,  even 
before  complete  syncope  has  ensued,  bsing  unable  either  to  see  or  hoar 


COMPLICATED    LABOR — CONCEALED    HEMORRHAGE,    ETC.        507 

anything  around  her,  and  if  relief  be  not  promptly  given,  the  hemor- 
rhage will  speedily  prove  fatal. 

TREATMENT. — In  all  cases  of  hemorrhage  previous  to  the  deliv- 
ery of  the  placenta,  there  is  but  one  course  to  pursue,  and  that  is, 
to  artificially  separate  and  remove  the  placenta,  and  "  no  man  is 
thoroughly  prepared  to  undertake  the  charge  of  a  common  midwifery 
case,  who  would  hesitate  to  pass  his  hand  into  the  uterus  and  remove  the 
placenta,  whether  adherent  or  detached/'  in  a  dangerous  flooding  of  this 
character;  and,  in  my  opinion,  the  sooner  this  operation  is  attempted 
the  greater  is  the  security  afforded  to  the  \voman;  do  not  wait  for  the 
hemorrhage  to  become  profuse  and-exhausting  before  interference. 

The  suddenness  and  profuseness  of  the  discharge  may  at  first  startle 
the  young  accoucheur — but  he  should  not  hesitate,  and  tamper  with  the 
case  by  endeavoring  to  extract  the  placenta  with  pulling  up  on  the 
cord,  because  he  may  invert  the  uterus  or  else  break  the  cord  off  in  the 
neighborhood  of  the  after-birth,  in  either  ca^-e  increasing  the  danger. 
It  will  be  well,  however,  to  make  slight  traction  on  the  cord  before  re- 
sorting to  more  radical  means,  as  it  may  be  wholly  or  almost  completely 
detached,  and  thus  easily  withdrawn.  Neither  should  he  attempt  to 
overcome  the  hemorrhage  by  internal  or  external  means  alone — leav- 
ing the  introduction  of  the  hand  as  a  dernier  resort — because,  in  these 
cases,  a  few  minutes  are  of  immense  value  to  the  patient,  and  such  de- 
lays are  trifling  with  her  life.  If  the  practitioner  becomes  excessively 
alarmed,  or  loses  his  presence  of  mind,  and  feels  a  hesitancy  as  to  the 
course  he  should  pursue,  he  should  not  attempt  interference,  lest  he 
might  increase  the  hazards,  but  should  at  once  send  for  counsel. 

On  the  manifestation  of  the  hemorrhage,  he  will  immediately  place 
a  bandage  around  his  patient's  abdomen  with  a  compress  beneath  it  to 
make  pressure  upon  the  uterine  fundus,  and  will  have  the  whole  firmly 
secured.  Then  removing  his  coat,  and  rolling  up  his  sleeves,  lie  will 
gently  stretch  the  cord  with  his  left  hand,  and  following  it  as  a  guide, 
conduct  his  right  hand  to  the  placenta ;  if  on  entering  the  os  uteri, 
this  be  found  contracted,  it  may  be  sufficiently  dilated  as  the  fingers 
and  hand  pass  through  it.  Upon  reaching  the  placenta,  the  fingers 
chould  be  extended  to  its  circumference,  and  its  adhering  portion 
slowly  and  cautiously  detached,  being  careful  that  the  separation  is 
complete  bpfore  attempting  its  removal  from  the  uterine  cavity.  After 
the  placenta  has  been  reached,  the  other  hand  should  be  placed  ex- 
ternally upon  the  abdomen  of  the  patient  to  support  and  steady  the 
uterus,  otherwise,  it  will  be  very  apt  to  move  about,  and  retard  the 
operation.  The  operator  must  bear  in  mind  that  by  following  the 
cord  he  will  reach  the  fetal  surface  of  the  placenta — and  should  he 


508  KINO'S    ECLECTIC    OBSTETRICS. 

become  embarrassed  by  the  membranes  in  his  search  for  its  periphery, 
the  hand  should  be  withdrawn  to  the  cervix,  placed  against  the  uter- 
ine walls,  and  the  fingers  carefully  passed  along  the  placenta. 

In  separating  the  placenta  from  the  uterus,  the  fingers  must  not  be 
passed  rudely  or  carelessly  between  the  adhering  surfaces,  lest  some 
portion  of  the  uterine  surface  be  injured  by  the  nails,  or  otherwise; 
neither  should  the  practitioner  seize  the  free  part  of  the  placenta  and 
draw  it  away,  lest  some  of  the  unseparated  placenta  be  torn  off  and 
left  behind  to  continue  the  hemorrhage  and  render  it  fatal,  or,  at  all 
events  to  decompose  and  ultimately  to  give  rise  to  the  usual  symptoms 
of  putrefactive  absorption.  But,  he  should  press  upon  the  placenta  at 
its  attached  points,  with  the  ends  of  his  fingers,  carefully  pushing  or 
pressing  it  off,  as  though  he  were  removing  the  peel  from  a  thin 
orange,  without  disturbing  the  inner  tunic  of  the  fruit  or  causing  any 
of  its  juice  to  exude. 

The  placenta  being  detached,  the  uterus  will  commonly  contract  and 
expel  it  and  the  hand  together ;  or  the  means  heretofore  advised  for 
causing  contractions  may  be  employed.  The  hand  must  not  be  with- 
drawn, but  must  be  expelled  by  the  uterine  contractions;  and  after 
the  expulsion,  contractions  occurring,  the  hemorrhage  will  cease. 
However,  should  it  still  continue,  it  must  be  treated  the  same  as 
flooding  occurring  after  placental  delivery. 

The  removal  of  the  placenta  is  not,  as  a  general  thing,  a  difficult 
operation;  sometimes,  however,  it  may  form  a  partial  or  complete 
morbid  adhesion  to  the  uterine  parietes,  when  it  must  be  detached 
according  to  the  mode  explained  when  treating  of  morbid  placental 
adhesion.  In  all  cases,  after  having  removed  the  placenta,  it  should 
be  carefully  examined  to  ascertain  whether  any  portion  of  it  is  left 
within  the  uterus,  and  if  any  considerable  part  of  it  be  wanting,  say, 
one-fourth,  or  one-third,  the  hand  should  be  immediately  re-intro- 
duced, to  remove  the  disrupted  part,  provided  the  uterus  has  not  in 
the  meantime  contracted  around  it. 

It  may  be  necessary  to  again  advert  to  a  rule  which  should  not  be 
disregarded;  which  is,  that  if  the  hemorrhage  has  been  very  great, 
causing  excessive  debility  and  syncope,  an  attempt  at  removing  the 
placenta  must  not  be  made  until  the  patient  rallies  a  little;  for  if, 
during  the  state  of  syncope  the  flooding  ceases,  the  introduction  of 
the  hand,  by  removing  the  clot  formed,  would  cause  a  return  of  the 
discharge  followed  by  almost  certain  death. 

In  this,  as  in  all  puerperal  floodings,  the  patient  must  not  be  left 
too  soon,  the  medical  attendant  should  remain  with  her  an  hour  or 


COMPLICATED    LABOR — HEMORRHAGE    AFTER     DELIVERY.     .509 

two  after  the  arrest  of  the  discharge,  for  the  purpose  of  knowing  that 
the  contraction  of  the  uterus  is  permanent,  and  that  there  will  be  but 
little  danger  of  a  return  of  the  flow,  and  which  may  generally  be 
insured  by  a  dose  or  two  of  Ergot,  as  soon  as  the  placenta  has  passed 
away,  together  with  a  firm  application  of  the  bandage ;  and  on  leaving 
the  house,  he  should,  previously,  give  full  instructions  to  the  nurse,  or 
some  friend,  how  to  proceed,  in  case  of  a  return  of  the  flooding. 
Measures  should  also  be  adopted  to  guard  against  an  attack  of  in- 
flammation. 

The  FOURTH  VAEIETY  of  uterine  hemorrhage,  is  that  which 
appears  after  the  extrusion  of  the  secundines ;  this  may  be  external 
and  apparent,  or  it  may  be  internal  and  concealed.  It  is  an  extremely 
dangerous  form  of  flooding,  often  manifests  itself  suddenly  and 
unexpectedly,  and  is  frequently  very  difficult  to  subdue.  It  is  com- 
monly owing  to  inertia,  or  want  of  contractions  of  the  uterus,  or 
perhaps  the  contractions,  may  be  irregular  and  unequal ;  occasionally, 
it  may  be  the  result  of  rupture  of  the  cervix,  and  will  be  severe  and 
dangerous,  in  proportion  to  the  extent  of*  the  rupture.  A  certain 
quantity  of  blood  always  escapes  from  the  mouths  of  the  uterine 
vessels,  after  delivery,  without  causing  any  alarming  or  serious  con- 
sequences, especially,  when  the  uterine  tumor  .is  found  hard  and  firmly 
contracted ;  but  when  the  system  experiences  the  effects  of  the  loss  of 
blood,  and  the  uterus  is  found  soft,  flabby,  and  uncontracted,  the 
patient  becomes  exposed  to  great  hazard.  Among  the  causes  which 
may  induce  inertia  of  the  uterus,  may  be  named,  mental  excitement, 
debility  of  the  muscular  fibers  of  the  uterus  after  a  labor  aided  by 
Ergot,  high  temperature  of  the  room,  reaction  from  the  use  of  stim- 
ulants, a  clot  filling  up  the  os  uteri,  constitutional  or  local  incapability 
of  muscular  contraction,  neglect  of  the  bandage,  meddlesome  inter- 
ference, etc.  Women  whose  urine  contains  considerable  albumen  are 
likewise  more  liable  to  this  variety  of  hemorrhage. 

The  hemorrhage  may  come  on  immediately  after  the  expulsion  of 
the  secundines,  even  when  the  labor  has  been  thus  far  favorable  and 
without  any  untoward  accidents;  or,  it  may  not  appear  for  half  an 
hour,  or  an  hour  after  the  delivery;  and,  sometimes,  several  hours  or 
even  days  may  intervene  before  the  effusion  is  manifested.  Usually, 
after  the  first  gush  of  blood  the  patient  faints,  and  the  discharge 
becomes  lessened  or  suspended;  she  rallies,  the  effusion  returns,  is 
again  succeeded  by  fainting  and  a  suspension  of  the  flow,  and  in  this 
manner  the  rallying,  flooding,  and  fainting  alternate,  until  the  system 


~)1()  KING'S    ECLECTIC    OBSTETRICS;. 

has  become  so  exhausted  that  reaction  is  impossible,  uud  death  ter- 
minates the  scene.  Sometimes,  the  discharge  will  take  place  slowly, 
continuing  for  some  time  before  the  patient  becomes  completely  lost  in 
a  fatal  syncope.  Again,  the  first  gush  is,  occasionally,  so  great  as  to 
produce  excessive  prostration  of  the  system,  with  syncope,  from  which 
the  patient  never  rallies.  The  influence  of  the  discharge  upon  the 
system,  varies  with  different  women ;  some  may  have  but  an  inconsid- 
erable degree  of  depression  from  an  excessive  flow,  while  others  will 
be  destroyed  by  the  loss  of  from  twelve  to  eighteen  ounces.  And  the 
hemorrhage  is  not  to  be  dreaded,  therefore,  so  much  from  its  quantity, 
as  from  its  effects  upon  the  constitution. 

SYMPTOMS. — This  form  of  hemorrhage  usually  comes  on  sud- 
denly, presenting  the  symptoms  common  to  copious  effusions  of 
blood.  Generally,  the  first  intimation  the  physician  has  of  the 
danger,  is  an  expression  from  the  patient  of  excessive  faintness:  her 
countenance  becomes  pale,  the  breathing  difficult  and  hurried,  the 
extremities  cold,  with  a  cold  perspiration  on  the  face  and  forehead, 
and  the  pulse  rapidly  becomes  small,  quick,  feeble,  fluttering,  indis- 
tinct, and  perhaps  entirely  suspended  for  a  few  beats,  accompanied 
with  a  state  of  unconsciousness,  which  often  comes  on  in  a  few  seconds. 
On  examining  the  bed  and  napkins,  a  large  quantity  of  blood  will  be 
found,  perhaps  so  excessive  as  to  find  its  way  from  the  bed  to  the 
floor;  or  there  may  be  a  very  small  discharge  externally,  but  a  copious 
one  internally. 

If  the  first  gush  should  not  prove  fatal,  after  a  greater  or  less  dura- 
tion of  the  syncope,  the  pulse  returns,  gradually  increasing  in  strength, 
the  countenance  becomes  a  little  more  florid,  the  extremities  warmer, 
the  breathing  more  natural,  and  the  patient  recovers  her  consciousness. 
If  the  system  has  been  considerably  depressed  by  the  discharge,  she1 
now  manifests  much  restlessness  and  uneasiness,  throwing  her  arms 
about,  gasping  and  crying  for  fresh  air,  to  be  fanned,  etc.,  Avitji 
anxious  expressions  and  apprehensions  of  dying. 

After  the  first  rally,  in  a  short  time  she  sinks  again  under  a  return 
of  the  hemorrhage,  from  which  she  may  again  recover,  and  so 
alternate  for  several  times  in  succession,  until  finally  she  complains 
3f  a  tightness  of  the  chest,  a  sense  of  suffocation,  which  may  be 
followed  by  a  few  spasmodic  struggles  or  convulsions,  terminating  in 
death.  The  fluttering,  indistinct  pulse,  the  pallid  countenance,  the 
hurried  respiration,  the  intolerable  restlessness,  with  rigors  and  vom- 
iting, are  indications  of  excessive  depression  of  the  physical  powers, 
requiring  prompt,  energetic,  and  decisive  measures,  which  must  be 


COMPLICATED    LABOR — HEMOREHAGE    AFTER   DELIVERY.        511 

perseveringly  persisted  in  until  the  patient  either  recovers,  or  sinks 
beyond  mortal  aid. 

The  hand  being  placed  upon  the  abdomen,  will,  in  case  of  internal 
hemorrhage,  find  the  uterus  soft  and  fluctuating,  and  of  a  size  nearly 
equaling  that  previous  to  the  delivery ;  and  if  pressure  be  made  upon 
it,  a  gurgling  sound  will  be  heard,  accompanied  with  a  gush  of  blood, 
fluid  or  coagulated,  from  the  vulva.  When  the  flooding  is  external, 
an  examination  of  the  bed  and  napkins  will  give  some  idea  of  the 
copiousness  of  the  discharge ;  and  although  the  uterus  will  be  found 
soft  and  flabby,  it  will  not  be  so  large  as  in  the  former  case. 

In  these  hemorrhages  after  delivery,  the  accoucheur  should  always 
ascertain  two  things :  first,  that  the  whole  of  the  placenta  has  been 
abstracted,  for  a  small  portion  retained  within  tjie  uterus  has  fre- 
quently given  rise  to  copious  flooding ;  and  when  called  in  to  a  case 
as  consulting  or  assisting  physician,  he  should  never  forget  to  ask  for 
the  placenta,  that  he  may  examine  it  carefully :  this  should  never  be 
omitted,  even  though  the  attending  physician  should  insist  that  it  had 
been  completely  removed;  for  cases  have  occurred  in  which  such 
assertions  have  been  found  erroneous — not  intentionally,  but  from  an 
insufficient  or  hasty  attention  to  the  matter.  Secondly,  ascertain  that 
the  uterus  is  not  inverted,  a  condition  which  may  be  readily  effected 
by  traction  upon  the  cord,  or  drawing  down  of  the  placenta,  when 
the  organ  is  in  a  relaxed  and  paralyzed  condition;  and  the  mode 
of  ascertaining  this  will  be  explained  under  the  head  of  Inverted 
Uterus. 

TREATMENT. — The  flooding  which  occurs  at  the  parturient 
period  is  not  owing  to  any  increased  or  inordinate  action  of  the  heart 
and  arteries,  and  is,  therefore,  a  passive  hemorrhage,  being  caused 
solely  by  the  exposure  and  patulous  condition  of  the  orifices  of  the 
uterine  blood-vessels,  the  result  of  placental  separation  and  non- 
contraction  of  the  uterus.  The  indications  of  treatment  are,  to  arouse 
the  contractions  of  the  uterus,  by  which  alone  can  we  expect  to 
suppress  or  check  the  hemorrhage,  and,  to  support  the  strength  of  the 
patient. 

If,  upon  examination,  it  be  ascertained  that  a  considerable  portion 
of  the  placenta  has  been  left  within  the  uterine  cavity,  the  hand  must 
be  immediately  introduced,  as  heretofore  stated,  for  the  purpose  of 
removing  it;  and,  usually,  the  uterus  will  contract  as  soon  as  the 
removal  is  effected,  thereby  arresting  any  further  flooding. 

But  the  placenta  may  have  been  entirely  removed,  and  still  a  pro- 
fuse hemorrhage  be  present;  the  woman's  safety,  then,  depends  entirely 


51 2  KING'S  ECLECTIC  OBSTETRICS. 

upon  the  induction  of  uterine  contraction.  The  practitioner  must 
proceed  calmly,  steadily,  and  energetically :  a  hesitation,  a  falter,  a 
timidity,  and  above  all,  an  inexcusable  ignorance  of  his  duties,  are 
almost  certain  death  to  his  patient.  Everything  around  is  calculated  to 
unman  him,  if  he  has  not  previously  instructed  and  prepared  himself; 
the  appalling  discharge  of  blood — the  sudden  pallor  of  countenance, 
depression  of  pulse,  and  loss  of  consciousness — the  intolerable  and 
significant  restlessness,  gaspings  for  air,  and  heart-rending  exclama- 
tions of  anticipated  death — together  with  the  alarm,  the  agonizing 
anxiety,  and  hurried  whisperings  and  questionings  of  friends,  are  but 
little  conducive  to  assist  him  in  tranquilizing  his  mind.  But  notwith- 
standing all  these,  he  must  be  composed,  positive,  prompt,  and  firm — 
must  subdue  all  his1  own  feelings,  for  the  safety  of  his  patient ;  and 
without  he  is  able  to  do  all  these,  he  is  unfit  for  the  responsible  duties 
of  an  accoucheur. 

The  hand  of  the  practitioner  must  be  placed  upon  the  abdomen  of 
his  patient,  for  the  purpose  of  making  firm  and  constant  pressure  over 
the  fundtis  uteri,  and  the  pressure  may  require  to  be  continued  for  two 
or  three  hours,  in  which  case  an  assistant  may  relieve  the  medical 
attendant  by  performing  this  manipulation,  and  which  will  always  be 
found  superior  to  a  bandage :  not  only  should  the  fundus  be  com- 
pressed, but  it  should  be  grasped,  squeezed,  kneaded  by  the  hand, 
which  will  tend  to  arouse  its  contractions,  as  well  as  to  prevent  it  from 
becoming  filled  and  distended  with  blood  and  clots;  and  this  should 
be  continued,  notwithstanding  the  patient  may  desire  us  to  desist  on 
account  of  the  pain  produced.  The  pressure  or  kueadings  should 
never  be  so  powerful  as  to  indent,  or  cause  a  partial  or  complete  inver- 
sion of  the  uterus.  Stimulants  should  be  freely  given  from  the  com- 
mencement of  the  hemorrhage,  or  sufficient  to  keep  up  the  pulse, — for 
this  purpose  brandy  will  be  found  very  efficient,  or  a  mixture  of  brandy 
and  Lloyd's  Ergot,  which  at  an  early  period  may  arouse  uterine  con- 
tractions, but  which  will  be  of  no  service  when,  from  excessive  loss 
of  blood,  there  is  also  a  corresponding  loss  of  the  absorbing  powers. 
Sulphate  of  Quinia,  given  internally,  or  by  subcutaneous  injection, 
will  frequently  prove  efficient  when  Ergot  fails.  The  hypodermic 
injection  often  or  fifteen  drops  of  Lloyd's  Ergot  will,  as  a  rule,  stim- 
ulate the  uterus  to  immediate  and  powerful  contraction,  and  in  ex- 
treme cases  should  be  administered  in  this  way.  When  the  flooding 
has  been  arrested,  a  bandage  and  compress  over  the  fundus  may  then 
be  substituted. 


COMPLICATED    LABOR HEMORRHAGE    AFTER    DELIVERY.       513 

If  the  hemorrhage  still  continues,  in  conjunction  with  the  pressure, 
cold  applications  should  be  applied  to  the  pelvis;  thus,  cold  \vater,  or 
a  mixture  of  cold  water  and  vinegar,  should  be  poured  upon  the  naked 
abdomen  from  a  considerable  height;  and  napkins  may  be  dipped  in 
the  same,  and  then  applied  suddenly  to  the  vulva,  the  thighs,  and  nates. 
And  this  treatment  should  be  persevered  in  until  the  shock  or  succes- 
sion of  shocks  arouses  uterine  action.  LIGATURES  should  be  applied 
around  the  thighs,  in  all  cases,  as  early  as  possible.  When  the  system 
becomes  considerably  depressed,  some  care  will  be  required  in  the 
resort  to  the  above  cold  applications,  as  their  constant  use,  at  this  time, 
will  be  apt  to  cause  injurious  rather  than  beneficial  results. 

Injections  of  Cold  Water  into  the  vagina,  uterus,  and  rectum,  and 
even  he  application  of  Ice  within  the  uterus,  have  been  advised,  but 
I  have  never  employed  them :  should  I  deem  such  means  requisite  at 
any  time  I  should  not  hesitate  to  employ  them. 

Internally,  Ergot  is  indicated,  but  it  will  frequently  fail  in  effecting 
any  beneficial  result.  I  place  great  confidence  in  the  exhibition  of 
tincture  of  Cinnamon,  which  undoubtedly  exerts  an  influence  upon  the 
uterus  :  it  may  be  given  in  teaspoonful  doses,  in  some  sweetened  water, 
and  repeated  every  ten,  thirty,  or  sixty  minutes,  according  to  the 
urgency  of  the  case;  or  it  may  be  beneficially  combined  with  other 
agents,  thus:  Take  of  tincture  of  Cinnamon,  tincture  of  Rhatany,  oil 
of  Turpentine,  each,  equal  parts  :  mix  together,  and  give  from  half  a 
fluidrachm  to  a  fluidrachm  for  a  dose,  in  some  convenient  vehicle,  and 
repeat  as  may  be  required.  Or  it  may  be  combined  with  Tannic  acid, 
tincture  of  Ergot,  and  Port  Wine.  But  it  must  be  recollected  that, 
however  valuable  they  may  be  in  other  cases,  astringents  are  of  but 
little  value  in  these  floodings,  unless  the  contraction  of  the  uterus  is- 
effected,  and  then  they  are  not  required.  It  is  only  in  instances  of 
moderate  flooding  where  these  agents  are  apparently  beneficial. 

The  calcined  Deer's  Horn  (See  American  Dispensatory]  has  been 
highly  recommended  in  uterine  hemorrhage  by  some  of  the  older 
Eclectics;  Several  report  having  always  succeeded  in  arresting  the 
discharge  when  other  means  have  failed.  I  have  not  employed  it  in 
practice,  having  succeeded  in  these  cases  by  the  means  above  de- 
scribed. Yet  its  positive  influence  in  checking  hemorrhage  has  been 
frequently  named  to  me  by  physicians  who  have  used  it,  and  whose 
statements  are  entitled  to  confidence;  beside,  I  know  of  instances 
where  it  has  been  exhibited  with  success.  It  is  generally  admin- 
istered in  drachm  doses,  repeated  every  ten,  twenty  or  thirty  min- 
utes; each  dose  may  be  added  to  about  a  gill  of  hot  water.  This 
33 


514  KING'S  ECLECTIC  OBSTETRICS. 

preparation  is  considered  a  powerful  styptic,  from  the  facility  with 
which  hemorrhages  are  checked  by  its  internal  use;  yet,  from  its 
beneficial  results  in  menorrhagia  and  uterine  hemorrhage,  it  must 
undoubtedly  exert  a  decided  influence  upon  the  uterus  itself,  inde- 
pendent of  any  styptic  power  it  may  possess. 

Other  agents  have  been  advised,  but  I  am  not  acquainted  with  any 
especial  value  they  possess,  for  instance — a  mixture  of  three  parts  of 
Alum,  two  of  Capsicum,  and  one  of  Geranium,  in  doses  of  twenty 
grains  every  ten,  twenty,  or  thirty  minutes.  Likewise,  doses  of  Tannic 
acid,  five  grains  mixed  with  half  a  grain  or  a  grain  of  Opium,  and 
repeated  according  to  indications.  It  makes,  however,  but  little 
matter  what  remedies  be  used,  so  that  the  most  important  indication 
be  fulfilled — energetic  and  permanent  uterine  contractions. 

Professor  Meigs  recommends  the  following  course,  in  obstinate  cases: 
"  If  the  student  should  find  the  hemorrhage  not  to  be  stayed  by  his 
treatment,  let  him  press  his  fingers,  gathered  into  a  cone,  firmly  down 
upon  the  aorta,  near  the  umbilicus.  If  the  patient  should  not  be 
troubled  with  extraordinary  obesity,  he  will  be  able  to  feel  the  throb 
of  the  aorta  with  the  points  of  the  fingers.  Let  him  compress  the 
tube  according  to  his  judgment,  in  such  a  way  as  to  check  the  down- 
ward rush  of  the  torrent.  This  will  operate  usefully  in  two  ways — 
first,  by  lessening  the  force  with  which  the  blood  reaches  the  bleeding 
orifices,  which  will  then  have  an  opportunity  to  close  themselves,  more 
or  less  completely;  and  second,  by  causing  a  greater  determination  of 
blood  to  the  encephalon,  whereby  the  tendency  to  deliquium  will  be 
lessened.  Many  lives  have  apparently  been  saved  by  thus  compressing 
the  aorta."  I  have  never  tested  this  method,  having  generally  succeeded 
in  checking  the  hemorrhage  by  the  means  above  named,  yet  I  have  no 
doubt  of  its  efficacy  in  some  cases,  and  can  bring  to  mind  instances  in 
which  it  might  have  been  the  means  of  saving  several  valuable  lives ; 
however,  I  should  not  hesitate  to  adopt  it  when  other  means  proved 
ineffectual,  and  would  favorably  recommend  it  to  the  attention  of  the 
student.  Baudelocque,  I  think,  advised  a  somewhat  similar  course. 

The  introduction  of  the  hand  within  the  uterine  cavity,  in  hemor- 
rnage  after  the  delivery  of  the  placenta,  for  the  purpose  of  stimulating 
the  uterus  to  act,  was  at  one  time  thought  to  be  a  most  injudicious 
procedure,  but  later  experience  shows  it  to  be  a  valuable  and  efficient 
means  in  overcoming  the  trouble  in  many  cases.  The  hand  im- 
mersed in  water  as  hot  as  can  be  borne,  and  then  carried  into  the 
uterus,  will  often,  from  its  reflex  effect,  produce  marked  uterine 
action.  In  Leishman's  System  of  Midwifery,  M.  Evrat  is  cited,  who 


COMPLICATED    LAIiOIl — HEMORRHAGE    AFTER    DELIVERY.       515 

recommended  the  use  of  a  peeled  lemon,  which  he  introduced  into  the 
cavity  of  the  uterus  and  then  squeezed,  so  as  to  project  the  acid  juice 
upon  the  bleeding  surface.  A  sponge  wrung  out  of  vinegar,  and 
other  astringents  have,  in  the  same  way  and  for  the  same  purpose, 
been  introduced,  and  the  effect  of  such  applications  has  not  unfre- 
quently  been  to  rouse  the  uterus  from  its  dormant  condition.  It 
may,  also,  frequently  be  necessary  to  introduce  the  hand  into  the 
uterus  for  the  removal  of  the  coagula,  which  sometimes  adhere  so 
strongly  to  the  inner  uterine  membrane  as  to  oppose  all  natural 
efforts  at  expulsion,  and  by  their  presence  keep  up  a  greater  or  less 
amount  of  flooding,  even  though  contractions  may  have  been  induced. 
The  coagulum  formed  within  the  uterine  cavity,  may  usually  be 
considered  as  a  means  adopted  by  nature  to  check  the  flooding,  as  well 
as  to  eventually  stimulate  the  organ  to  contraction.  In  many  instances, 
the  introduction  of  the  hand,  with  frictions  internally  and  externally, 
and  aided  by  Ergot,  fail  to  arouse  the  activity  of  the  uterus;  it  continues 
soft  and  flabby,  and  if  the  coagula  are  removed  with  the  womb  in  this 
inert  condition,  it  may  be  followed  by  a  fatal  increase  of  the  hemorrhage. 
The  safety  of  the  woman,  in  such  case,  depends  entirely  upon  the 
presence  of  the  coagula,  and  its  continuance  until  contractions  are 
excited,  when  they  will,  as  a  general  rule,  be  expelled  without  artificial 
aid.  Again  :  should  the  uterus  be  suddenly  aroused,  as  has  been  the 
case,  and  contract  upon  the  hand  within  its  cavity,  the  position  of  the 
accoucheur,  as  well  as  of  his  patient,  will  be,  at  least  for  a  time,  any- 
thing but  agreeable — the  hand  being  fastened  within  a  firmly-contracted, 
womb.  An  artificial  removal  of  the  clots,  however,  is  advisable 
where  there  has  been  a  failure  of  the  other  means  employed,  with 
considerable  distension  of  the  uterus,  and  symptoms  indicative  of  a 
flow  internally;  here,  the  removal  of  the  coagula,  followed  by  active 
means  to  secure  uterine  contraction,  will  prove  serviceable,  but  it 
should  be  undertaken  with  cautiousness  and  prudence,  because,  if  we 
fail  to  induce  the  desired  contractions,  the  consequences  to  the  patient 
become  more  serious.  A  removal  of  the  coagula  may  likewise  be 
attempted  in  cases  where  the  uterus  is  small,  with  contractions  or  a 
disposition  to  become  firm,  but  where,  notwithstanding,  the  flow  of 
blood  continues  in  great  quantity;  in  these  cases  the  clots  are  usually 
so  firmly  agglutinated  to  the  inner  walls  of  the  uterus  that  the  efforts 
of  the  organ  can  not  expel  them.  Any  great  accumulation  of  coagula, 
however,  will  not  be  apt  to  take  place,  if  strong  pressure  or  kneading 
be  applied  over  the  fundus  uteri  by  the  hand,  or  by  a  properly  adjusted 
compress  and  bandage :  it  is.  the  neglect  of  this  measure  which  fre- 


516  KING'S  ECLECTIC  OI:STKTIMCS. 

quently  occasions  the  difficulty.  When  the  external  hemorrhage  has 
not  been  threat,  but  the  constitutional  symptoms  indicate  the  loss  of 
much  blood,  and  there  is  but  little  distension  of  the  uterus,  an  exami- 
nation may  find  the  vagina  filled  with  a  coagulum,  and  this  should  be 
at  once  removed. 

Dr.  Rigby  speaks  favorably  of  applying  the  child  to  the  mother's 
breast,  in  this  variety  of  flooding;  suckling  frequently  induces  after- 
pains,  and  from,  the  sympathy  existing  between  the  uterus  and  mammae, 
it  maybe  found  an  efficacious  method  of  causing  the  uterus  to  contract: 
if  the  plan  be  tried,  the  mother  should  not  be  moved  or  disturbed  in 
her  position.  Galvanism  has  been  recommended  by  Dr.  Radford, 
and  there  is  no  doubt  but  it  will  prove  successful  in  many  instances, 
provided  the  battery  can  be  prepared  and  in  readiness  for  immediate- 
action. 

Among  other  measures,  recently  advised  in  this  dangerous  complica- 
tion of  labor,  may  be  named  that  of  M.  Dupierris,  of  Havana,  and 
which  he  has  successfully  used  in  more  than  one  hundred  cases  of 
uterine  hemorrhage:  he  first  removes  the  clots  and  other  foreign 
bodies  from  the  uterine  cavity,  and  then  slowly  and  carefully  injects 
into  this  cavity  a  mixture  composed  of  tincture  of  Iodine  half  a  fluid- 
ounce,  Iodide  of  Potassium  ten  grains,  Distilled  Water  one  fluidounce. 
He  states  that  it  promptly  arrests  the  hemorrhage  by  arousing  the 
uterus  to  contractions,  seldom  having  to  give  a  second  injection ; 
beside  which,  he  has  found  this  injection  to  be  of  great  value  in 
puerperal  peritonitis. 

A  great  deal  of  discussion,  and,  unfortunately,  some  of  it  of  a  per- 
sonal character,  has  been  carried  on  among  the  medical  men  of  Great 
Britain,  relative  to  the  use  of  perchloride  of  iron  in  post-partum 
hemorrhage,  many  contending  that  it  is  a  dangerous  agent,  while  others 
equally  as  eminent  in  the  profession  deny  this,  and  speak  highly  of  its 
efficacy  in  their  hands.  It  appears  that  perchloride  of  iron  was  first 
successfully  used  by  the  late  Professor  d'Outrepont,  of  Wurzburg,  some 
thirty  years  ago;  recently  the  attention  of  the  profession  has  been  more 
directly  called  to  it,  from  its  strong  recommendation  by  Dr.  Barnes, 
of  England.  The  objections  to  its  use  are,  that  it  gives  rise  to  violent 
after-pains,  embolism,  phlegmasia  dolens,  pyaemia,  metritis,  septicaemia, 
or  peritonitis,  and  generally  followed  by  death.  Unless  the  fluid  be 
forced  into  the  abdominal  cavity,  or  the  clots  formed  by  its  constringing 
action  be  not  removed  from  time  to  time,  thus  allowing  them  to  remain 
and  decompose  in  the  uterine  cavity,  I  can  not  comprehend  how  such 
serious  effects  can  follow  its  employment  except  as  mere  coincidences 
— the  contractions  of  the  uterus  which  immediately  follow  its  applica- 


COMPLICATED    LABOR — HEMORRHAGE    AFTER    DELIVERY.       517 

tion,  and  the  closure  of  the  mouths  of  the  bleeding  vessels,  are  certainly 
opposed  to  any  supposition  that  such  results  are  due  to  its  use.  The 
successful  results  following  its  employment  that  are  recorded  by  some 
of  the  most  skillful  and  eminent  •  medical  men  in  Europe  and  this 
country,  certainly  entitle  it  to  a  just  and  fair  consideration. 

This  agent  should  only  be  used  as  a  dernier  ressort,  when  all  the  other 
means  pursued  have  failed,  and  especially  in  those  cases  where  the 
uterus  contracts  and  relaxes  alternately,  and,  if  possible,  it  should  not 
be  delayed  too  long,  but  should  be  resorted  to  before  the  exhaustion 
becomes  so  great  that  the  uterus  is  rendered  incapable  of  responding 
to  the  stimulus.  Immediately  previous  to  injecting  it,  all  clots  or 
remaining  portions  of  placenta  structure  should  be  carefully  removed 
from  the  uterine  cavity,  to  allow  the  agent  to  come  in  direct  contact 
with  the  bleeding  surface;  and  the  extremity  of  the  nozzle  of  the 
injecting  tube  should  be  passed  up  to  the  uterine  fundus,  the  fluid 
being  carefully  and  slowly  injected,  especially  avoiding  the  injection 
of  air  at  the  same  time.  It  has  likewise  been  used  by  swabbing  out 
the  uterine  cavity  with  a  small  brush  moistened  with  it,  or  by  saturating 
soft,  fine  sponge  with  it,  with  which  the  uterine  surface  is  swabbed, — 
allowing  the  sponge  to  be  expelled  by  the  contractions  thus  excited;  a 
string  may  be  attached  to  the  lower  extremity  of  the  sponge,  by  which 
it  may  be  withdrawn  if  desired. 

A  day  or  so  after  the  cessation  of  the  hemorrhage,  and  when  any 
further  danger  from  it  has  passed,  the  hard,  black  clots  formed  by  the 
corrugating  eifects  of  the  perchloride,  should  be  removed  from  time  to 
time  in  order  to  prevent  any  evil  effects  from  their  decomposition;  and 
to  assist  in  this  prevention,  solution  of  Permanganate  of  Potassa  may 
be  injected  (or  swabbed)  three  or  four  times  a  day  into  the  uterine 
cavity,  until  all  danger  from  septic  absorption  has  passed.  At  the 
same  time  a  proper  sustaining  treatment  must  be  pursued.  Secondary 
hemorrhage  has  in  a  few  instances  occurred  some  ten  or  twelve  days 
after  delivery,  due  to  retained  clots,  etc.,  but  which  has  been  overcome 
by  further  injections  of  a  strong  solution  of  the  perchloride.  The 
strength  of  the  solution  injected  has  varied  with  practitioners,  as,  1 
part  of  solution  of  Perchloride  of  Iron  to  32  parts  of  water ;  and  1 
part  to  6,  4,  and  2  parts  of  water — 1  part  of  iron  to  4  of  water  being 
the  strength  more  commonly  used.  Although  I  have  never  used  this 
agent,  having  met  with  success  in  post  partum  hemorrhage  from  the 
measures  heretofore  recommended,  yet  should  these  ever  fail  me,  I 
should  not  hesitate  to  employ  the  one  under  consideration,  deeming  it 
safe  and  justifiable,  and  should  employ  1  part  to  15  or  20  of  water. 


518  KING'S  ECLECTIC  OBSTETRICS. 

An  important  point,  to  which  I  have  heretofore  adverted,  is  not  to> 
interfere  when  syncope  is  present.  Any  depression  of  vascular  action 
is  favorable  to  coagulation  of  the  blood,  and  we  most  commonly  find  a 
cessation  of  the  discharge  while  the  patient  lies  in  this  condition;  and 
an  attempt,  at  this  time,  to  introduce  the  hand  within  the  uterus,  or  to 
inject  fluids  into  its  cavity,  may,  by  removing  the  clots  formed,  occasion 
a  fatal  renewal  of  the  hemorrhage.  Neither  should  stimulants  bo 
given  unless  absolutely  required,  because  the  sudden  increase  in  arterial 
action  occasioned  by  their  exhibition  may  not  only  prevent  a  coagulum 
from  forming,  but  may  also  remove  that  which  has  already  been 
deposited  over  the  orifices  of  the  bleeding  vessels — of  course,  increasing 
the  dangers  of  the  hemorrhage. 

Indeed,  stimulants  are  only  to  be  administered  when  the  system  has 
become  considerably  depressed,  and  when  there  is  reason  to  fear  that 
the  syncope  would  prove  mortal:  then  the  vascular  action  must  be 
sustained  and  the  vital  energies  aroused,  as  •  indispensable  measmv.-. 
Brandy,  rum,  ether,  ammonia,  cordials,  etc.,  may  be  given,  as  heretofore 
recommended  in  hemorrhage  from  placenta  prsevia.  At  this  time,  it 
will  be  extremely  improper  to  continue  the  local  applications  of  cold, 
as  their  influence  will  be  to  augment  the  depression  of  the  system. 

Some  writers  have  advised  the  employment  of  the  tampon,  but  it  is 
bad  practice.  The  danger  of  giving  rise  to  a  concealed  hemorrhage 
should  always  deter  us  from  using  the  tampon  in  uterine  hemorrhage 
occurring,  especially  at  the  parturient  period,  unless,  indeed,  we  except 
the  instances  of  placenta  praevia  already  referred  to. 

In  cases  of  excessive  prostration,  transfusion  has  been  advised.  I 
have  no  knowledge  of  its  effects  from  my  own  experience,  but  the 
recorded  instances,  of  some  years  past,  with  which  I  have  become 
acquainted  did  not  tend  to  give  me  any  exalted  opinion  of  it.  Still, 
lives  have  been  saved  by  it,  and  the  late  improvements  in  the  instru- 
ments, etc.,  employed  .for  this  purpose,  render  it  very  probable  that 
very  many  more  will  be.  It  should  be  resorted  to  in  all  cases,  when 
possible,  where  loss  of  blood  alone  is  rapidly  destroying  life. 

THE  AFTER-TREATMENT  OF  HEMORRHAGE  requires 
some  attention  :  for  although  the  discharge  may  be  arrested,  and  the 
uterus  contracted,  yet  there  may  be  a  return  of  relaxation  of  the  uterine 
muscular  fibers,  with  an  accompanying  flow ;  hence  many  hours  may 
pass  before  the  patient  will  be  entirely  free  from  this  danger.  As  soon 
as  the  flooding  has  been  arrested  by  the  means  employed  for  that  pur- 
pose, a  bandage  should  be  firmly  applied  around  the  body,  so  as  to 
secure  a  steady  compression  over  the  fundus  uteri :  a  thick  compress 


COMPLICATED  LABOR — AFTER-TREATMENT  OF  HEMORRHAGE.   519 

placed  between  the  abdomen  and  the  bandage,  will  materially  aid  in 
accomplishing  the  desired  object,  viz::  to  prevent  the  occurrence  of  any 
relaxation  of  the  uterine  fibers.  The  bandage  should  be  examined 
every  hour  or  two,  to  ascertain  that  it  has  not  moved,  but  remains  in 
its  proper  situation  :  it  frequently  happens,  that  when  the  bandage 
becomes  loosened,  or  disturbed  from  its  proper  position,  there  will  be 
a  return  of  the  hemorrhage,  and  of  the  relaxed  condition  of  the  uterus. 
The  ligatures  which  were  applied  around  the  thighs  may  be  loosened, 
but  they  should  not  be  removed,  at  least,  until  a  sufficient  time  has 
elapsed  to  guarantee  the  safety  of  the  woman  from  further  hemorrhage. 
Upon  no  account  whatever  must  she  be  allowed  to  move  for  some 
hours,  proportioned  to  the  severity  of  the  attack.  In  a  moderate  flow, 
she  may  be  "  put  to  bed "  carefully,  and  her  linen  changed,  in  the 
course  of  five  or  six  hours  after  its  cessation;  but  in  profuse  and 
exhausting  attacks,  twelve  or  eighteen  hours  may  elapse  before  it  will 
be  proper  to  attempt  her  removal.  Sudden  death  has  frequently 
occurred  by  raising  -the  patient  in  a  sitting  posture,  for  any  purpose; 
and  even  a  mere  change  of  position  from  one  side  of  the  bed  to  the 
other,  has  resulted  fatally.  The  practitioner  will,  therefore,  see  the 
absolute  necessity  for  strictly  enjoining  a  state  of  quiescence  for  a  suffi- 
cient length  of  time.  It  is  always  better  to  keep  the  head  somewhat 
lower  than  the  body.  As  it  would  be  imprudent  to  allow  the  patient 
to  lie  in  the  damp  and  moisture  around  her  for  any  length  of  time, 
means  must  be  adopted  to  render  her  comfortable  and  dry,  without 
moving  her  in  the  least,  or  allowing  her  position  to  be  changed.  A 
blanket,  or  something  of  the  sort,  may  be  slowly  and  carefully  insin- 
uated beneath  her,  in  such  a  manner  as  to  effect  the  desired  result. 

To  favor  a  state  of  rest,  as  well  as  to  moderate  any  irritability 
of  the  system,  the  compound  powder  of  Ipecacuanha  and  Opium 
may  be  administered  in  a  dose  of  five  grains,  or  a  powder  com- 
posed of  Capsicum  five  grains,  Ipecacuanha  one  grain,  Opium  half 
a  grain,  may  be  administered  every  hour  or  two,  as  indicated;  the 
addition  of  Capsicum  has  an  undoubted  tendency,  it  is  claimed, 
to  prevent  a  return  of  the  hemorrhage,  in  a  majority  of  cases. 
The  apartment  in  which  the  female  lies  should  be  well  venti- 
lated, darkened,  and  the  temperature  must  not  be  too  elevated. 
If  much  exhaustion  is  present,  cold,  nourishing,  and  easily 
digested  fluids  may  be  given  at  short  and  regular  periods,  as 
gruel,  beef  tea,  etc. ;  and  when  the  prostration  is  excessive,  some 
stimulant  may  be  added.  Visitors  must  positively  be  forbidden: 
%no  one  is  required  to  be  in  the  room,  save  the  physician,  nurse,  and 


520  KING'S  ECLECTIC  OBSTETRICS. 

husband.  Talking,  or  mental  excitement,  whether  pleasurable  or  not, 
is  very  apt  to  induce  a  return  of  the  flow,  and  should  be  prohibited. 

In  cases  where  the  hemorrhage  has  not  been  profuse,  the  practitioner 
should  not  leave  the  patient  for  two  or  three  hours;  but  in  the  more 
copious  and  exhausting  discharges,  the  female  is  not  thoroughly  safe 
until  five  or  six  hours  have  elapsed  since  their  arrest;  and  she  should 
not  be  left,  in  these  instances,  until  this  period  has  passed  by.  A  care- 
ful and  conscientious  accoucheur  will  never  leave  his  patient  at  too 
early  a  period,  but  will  remain  and  watch  her  closely.  If  the  pulse 
be  quick,  compressible,  and  jerking,  indicative  of  hemorrhage,  he  will 
be  011  his  guard,  and  prepared  to  meet  it  on  its  first  appearance. 

When  females  are  liable  to  attacks  of  hemorrhage  after  the 
expulsion  of  the  child,  or  placenta,  it  may  frequently  be  prevented 
by  the  use  of  some  uterine  tonic  during  the  last  three  or  four 
months  of  utero- gestation ;  as,  for  instance,  the  Parturient  Balm, 
Sp.  Tr.  Macrotys,  Aletris,  etc.  And  at  the  time  of  labor,  the  os 
uteri  being  dilatable,  the  membranes  may  be  ruptured  at  an  early 
period,  when  the  presentation  is  natural;  and  as  soon  as  the  child 
is  born,  the  bandage  and  compress  over  the  fundus  uteri  should  be 
firmly  applied. 

In  cases  of  excessive  hemorrhage,  and  after  the  patient,  has  fully 
recovered  from  the  syncope,  a  powerful  reaction  usually  ensues,  accom- 
panied with  a  greater  or  less  degree  of  nervous  irritability.  The 
velocity  of  the  circulation  becomes  increased  in  proportion  to  the 
decrease  which  the  blood  has  experienced,  its  momentum  probably 
atoning  for  the  deficiency  in  quantity.  Fever  is  commonly  present 
when  this  reaction  occurs. 

There  will  be  throbbing  of  the  temples,  a  distressing  pain  in  the 
head,  vertigo,  ringing  in  the  ears,  and  an  intolerance  of  noise,  and 
occasionally  of  light.  In  nearly  every  case  pain  in  the  head  will  be 
complained  of,  accompanied  with  a  sensation  or  noise,  which  may  be 
variously  compared  to  the  beating  of  a  small  hammer  within  the  skull, 
the  ticking  of  a  clock,  the  singing  of  a  tea-kettle,  or  the  roaring  of  the 
sea,  and  which  is  probably  owing  to  the  forcible  contraction  of  the 
arteries  upon  the  diminished  amount  of  blood  contained  in  them,  pro- 
pelling it  onward  by  jerks.  The  pulse  will  be  quick,  small,  jerking, 
and  wiry  or  compressible ;  the  least  motion  causes  great  disquietude ; 
there  will  be  a  sense  of  faintness  and  of  impending  dissolution, 
especially  on  being  raised  from  the  pillow.  The  skin  becomes  hot 
and  dry,  the  mouth  dry  and  parched,  and  the  features  are  shriveled, 


COMPLICATED  LABOR — AFTER-TREATMENT  OF  HEMORRHAGE.    O'21 

vvith  a  contracted  state  of  the  lips  and  nose.  Palpitations  or  flutter- 
ings  of  the  heart  are  often  present,  as  well  as  panting,  sighing, 
moaning,  dyspnoea,  and  sometimes  a  hacking,  irritating  cough.  Fresh 
air  or  the  smelling-bottle  will  frequently  be  called  for.  On  awaking 
from  sleep,  or  on  being  suddenly  disturbed,  the  patient  will  exhibit  a 
degree  of  hurry  and  alarm.  Sometimes  there  will  be  retching,  or 
vomiting,  hiccough,  and  a  dislike  for  solid  food.  All  the  secretions 
become  lessened,  the  bowels  are  flatulent,  and  constipation  or  diarrhea 
may  be  present.  Wakefulness  is  not  uncommon.  Various  organs,  as 
the  peritoneum,  pleura,  or  brain,  may  present  symptoms  of  inflamma- 
tion ;  and  upon  arising  or  assuming  the  erect  position,  death  may 
suddenly  occur. 

These  symptoms  will,  of  course,  vary,  both  in  kind  and  degree,  in 
different  females,  depending  on  the  extent  of  prostration  and  other 
concomitant  circumstances ;  but  the  peculiar  pain  and  noise  in  the 
head  will  very  rarely  be  absent. 

TREATMENT. — The  above  disagreeable  conditions  are  dependent 
on  a  diminution  of  the  quantity  of  blood  in  the  system,  and  the  indi- 
cations will  be,  to  increase  the  amount  of  blood,  to  impart  tone  and 
vigor  to  the  constitution,  and  to  remove  the  various  unpleasant  symp- 
toms with  which  the  patient  is  annoyed. 

To  fulfill  the  first  and  second  indications,  it  will  be  necessary  to 
allow  the  patient  nutritious  and  easily-digested  articles  of  diet,  as 
boiled  milk,  arrowroot,  calf's-foot  jelly,  beef,  mutton,  and  chicken 
broths,  oyster  soup,  custard,  soft-boiled  eggs,  Indian-meal  gruel,  etc. 
If  required,  wine  or  brandy  may  be  added  to  the  diet,  and  even  ale 
or  porter  is  admissible  in  some  cases  ;  but  all  stimuli  should  be  allowed 
with  much  .caution.  The  nourishment  should  be  given  at  regular 
periods,  and  in  small  quantities,  so  as  not  to  oppress  or  offend  the 
stomach. 

For  the  removal  of  annoying  symptoms  several  means  may  be  re- 
quired. Thus,  the  heat  and  dryness  of  the  surface  may  be  relieved 
by  sponging  the  head,  body,  and  limbs  with  cold  or  tepid  water,  or 
vinegar,  as  circumstances  will  indicate:  the  Sp.  Tr.  Pulsatilla  wii; 
likewise  assist  in  the  accomplishment  of  this  result,  as  well  as  to 
allay  nerv7ous  irritability  and  relieve  the  distress  in  the  head;  and 
the'  patient  should  be  kept  in  a  cool  and  well  ventilated  room,  and 
in  a  state  of  perfect  quiet  and  rest.  Where  Opium,  or  its  salts  of 
Morphia,  are  called  for,  and  disagree,  other  agents  may  be  advan- 
tageously exhibited,  a.s  Sp.  Trs.  Hyoscyamus,  Gelsemium,  or  a  few 


522  KING'S   KCLKCTIC  OBSTETRICS. 

doses  ol'  Bromide  of  Potassium,  etc.  The  Sp.  Trs.  of  Hyoseyamus, 
Pulsatilla,  KhusTox.  or  Aconite  will  frequently  afford  much  relief  in 
allaying  pain  and  nervous  irritation;  they  should  be  given  either 
singly  or  in  such  combinations  as  indications  direct.  As  little  medi- 
cine as  possible  should  be  employed  in  these  oases;  the  greatest 
reliance  must  be  placed  upon  fresb  air,  quiet,  and  nourishment. 

Constipation  maybe  treated  by  Seidlitz  powders;  by  the  mixt- 
ure of  Rhubarb  two  parts,  and  Bicarbonate  of  Potassa  one  part, 
heretofore  referred  to;  or  by  rectal  injections.  But  in  all  instances 
active  medication  of  any  kind  must  be  positively  avoided.  The  dis- 
tress in  the  head,  quick  pulse,  fever,  constipation,  etc.,  may  lead  the 
young  accoucheur  to  suppose  that  relief  will  be  obtained  by  an  active 
purge,  which,  if  administered,  may  prove  injurious  to  his  patient. 
The  difficulty,  as  before  remarked,  is  due  to  the  loss  of  blood,  and  not 
to  any  determination  of  this  fluid  to*  the  brain  or  other  organ ;  and  so 
soon  as  the  blood-vessels  become  filled  with  the  necessary  amount  of 
their  proper  fluid,  all  the  symptoms  will  disappear.  However,  should 
the  face,  instead  of  the  usual  pale  appearance,  become  tumid  and 
slightly  florid,  from  an  excess  of  blood  in  the  veins,  warm  applications 
may  be  applied  to  the  feet  and  limbs,  with  cold  to  the  face  and  head, 
for  the  purpose  of  equalizing  the  circulation. 

The  patient  must  not  be  allowed  to  get  up,  for  any  purpose  what- 
ever, until  all  the  above-described  symptoms  have  disappeared;  and 
when  this  is  attempted,  care  must  be  taken  that  it  be  effected  slowly, 
and  that  at  first  the  sittings  be  for  a  very  short  period  only.  And 
should  the  sitting  posture  occasion  a  sensation  of  faintness,  it  must  be 
dispensed  with,  and  not  tried  again  for  a  few  days.  Too  much  atten- 
tion can  not  be  paid  to  this  point. 


CHAPTER    XXXIX. 

COMPLICATED    LABOR — RETENTION    OF    THE    PLACENTA — HOUR- 
GLASS  CONTRACTION— MORBID    ADHESION    OF    THE 
PLACENTA PYTREFACTIVE    ABSORPTION. 

IN  primiparse,  the  placenta,  in  the  greater  number  of  instances, 
immediately  follows  the  expulsion  of  the  child,  and  with  others  it 
usually  comes  away  in  from  five  to  twenty  minutes  thereafter;  bin 
cases  frequently  occur  in  which  it  remains  without  hemorrhage  for 


COMPLICATE!)  LABOR — RETENTION  OF  THE  PLACENTA,  ETC.  523 

houiv,  or  even  days,  if  permitted,  before  it  will  pass  off;  and  whenever 
it  is  not  expelled  within  an  hour  after  the  birth  of  the  child,  it  is 
called  a  retained  placenta. 

Young  accoucheurs  frequently  mistake  a  delayed  appearance  of  the 
placenta  for  a  retention ;  thus,  the  mass  may  be  detached  and  lie 
loosely  within  the  cavity  of  the  uterus,  or  within  the  upper  part  of 
the  vagina,  or  partly  within  each,  and  not  advancing  any  further,  may 
be  erroneously  considered  a  retention;  whereas,  some  simple  expedient, 
as  firmly  grasping  the  fundus  uteri,  the  patient  blowing  in  her  hand  or 
in  a  bottle,  sneezing,  coughing,  bearing  down,  or  artificially  producing 
retelling,  will  at  once  liberate  it.  Ordinarily,  the  last  uterine  pains 
which  effect  the  delivery  of  the  child,  either  completely  or  partially 
detach  the  placenta,  and  the  mass  will  remain  within  the  cavity  of 
the  organ  until  expelled  by  a  return  of  its  contractions.  When  the 
detachment  is  partial,  or  even  when  complete,  dangerous  hemorrhage 
may  ensue,  especially  when  the  uterus  is  in  a  state  of  inertia.  If, 
however,  no  detachment  has  taken  place,  and  the  placenta  is  entirely 
adherent  to  the  uterus,  there  will  be  no  immediate  danger  from 
flooding. 

The  placenta  may  be  retained  without  accompanying  hemorrhage, 
and  instances  are  recorded  where  it  has  remained  within  the  uterus 
for  several  days  without  causing  any  bad  effects:  cases  have  likewise 
been  met  with  where  it  never  left  the  uterus,  having  been,  probably, 
absorbed  by  the  uterine  vessels.  Several  authors  have  counseled  us 
not  to  extract  the  placenta  at  all,  unless  hemorrhage  be  present,  but 
leave  it  entirely  to  the  natural  powers;  it  has,  however,  been  found 
by  experience  that,  more  commonly,  an  attention  to  this  advice  is 
fraught  with  danger  to  the  female,  who  becomes  thereby  exposed  to 
hemorrhage,  uterine  inflammation,  or  constitutional  irritation  (sep- 
ticaemia) from  absorption  of  putrid  animal  matter,  as  marked  by 
vomiting,  purging,  and  typhoid  symptoms.  Severe  after-pains  fre- 
quently accompany  a  retained  placenta,  but  while  these  exist,  they 
are  useful,  being  evidences  of  the  contractions  of  the  uterus;  still,  the 
female  often  suifers  unnecessarily  from  them,  by  not  having  the  after- 
birth expelled. 

An  accoucheur  should  never  leave  his  patient  with  the  placenta 
undelivered,  because  she  is  not  safe  while  it  remains  within  the  uterine 
cavity ;  beside,  any  uncommon  delay  will  give  rise  to  mental  excite- 
ment and  anxiety,  from  an  apprehension  on  her  part  that  he  is  not 
thoroughly  versed  in  his  profession,  or  else  that  there  is  some  great 
danger  present.  Her  friends  will  likewise  be  very  apt  to  increase  her 


524  KIN(i's    KC'LECTIC    OBiSTKTRK  S. 

agitation  and  fears  by  whispered  suggestions  of  a  similar  character. 
And  in  case  of  a  retention,  he  should  remain  for  an  hour  or  two  with 
her  after  the  cake  has  been  extracted,  to  guard  against  subsequent 
hemorrhage. 

In  259,250  cases,  retention  of  the  placenta  occurred  293  times,  or 
about  1  in  661 J;  in  186  cases,  36  died,  or  about  1  in  5;  the  immediate 
cause  of  the  fatality  being  hemorrhage. — (Churchill.}  Three  causes 
have  been  assigned  for  this  difficulty: — 1,  inertia  of  the  uterus,  or 
want  of  uterine  contraction;  2,  spasmodic  or  irregular  contraction  of 
the  uterus;  and  3,  morbid  adhesion  of  the  placenta  to  the  uterus. 
These  causes  and  their  treatment  will  be  considered  separately.— 
Although  arranged  under  different  heads,  it  may  be  stated  here,  that 
rigidity  of  the  os  uteri,  hour-glass  contraction,  inversion  of  the  uterus, 
and  violent  after-pains  are  convertible  symptoms  due  to  the  same 
cause, — irregular  uterine  action,  requiring  similar  treatment  with 
proper  modifications. 

1.  RETENTION  OF  THE  PLACENTA,  FROM  INERTIA 
OF  THE  UTERUS,  more  frequently  occurs  after  a  difficult,  pro- 
tracted labor,  though  it  may  be  due  to  a  large  pelvis,  in  which  the 
uterus  is  allowed  to  suddenly  evacuate  its  contents — but,  in  the  latter 
instance,  hemorrhage  is  apt  to  ensue,  before  the  organ  can  sufficiently 
recover,  from  its  abrupt  disgorgement,  to  contract. 

Upon  placing  the  hand  on  the  abdomen,  the  uterus,  instead  of  being 
firm,  hard,  and  well  defined,  indications  of  its  normal  contraction, 
will  be  found  large,  soft,  and  flabby,  scarcely  distinguishable  through  the 
abdominal  parietes,  from  the  other  viscera  in  the  hypogastrium  ;  there 
will  be  no  pains,  or,  if  they  do  occur,  they  will  be  very  feeble  and 
indistinct. 

TREATMENT. — Retention  of  the  placenta,  with  accompanying 
hemorrhage,  has  already  been  considered ;  those  cases  will  now  be 
referred  to,  in  which  flooding  is  absent. 

The  principal  indication  is,  to  adopt  measures  to  induce  uterine  con- 
traction. For  this  purpose,  frictions  and  firm  pressure  with  the  palm 
of  the  hand  over  the  fundus  uteri,  and  at  the  same  time  gentle  trac- 
tions upon  the  umbilical  cord  in  the  direction  of  the  axis  of  the 
superior  strait,  should  be  made.  In  compressing  the  uterine  globe,  in 
all  cases  where  it  is  in  a  soft  and  flabby  condition,  much  care  should 
be  taken  not  to  indent  the  organ,  lest  an  inversion  of  it  be  effected— 
for  in  a  relaxed  state,  it  will  be  an  easy  matter  fo-r  a  careless  or  ignorant, 
person  to  cause  such  a  depression  by  exerting  an  unnecessary  amount 


COMPLICATED  LABOR — RETENTION  OF  THE  PLACENTA,  ETC.   525 

of  pressure.  Again,  in  making  tractions  upon  the  cord,  too  much 
force  must  be  avoided,  else  it  may  be  torn  from  the  placenta:  or  the 
placenta  may  be  forced  from  its  uterine  attachment,  giving  rise  to  pro- 
fuse and  dangerous  flooding;  or  the  uterus  may  be  either  prolapsed  or 
inverted.  Slight  tractions  upon  the  cord,  to  solicit  or  arouse  the 
uterus  to  action,  are  allowable;  but  no  attempts  to  draw  out  the  pla- 
centa by  it  should  ever  be  made  while  the  uterus  is  in  a  relaxed  condi- 
tion ;  any  effort  of  this  kind  should  only  be  attempted  when  the  organ 
is  contracted,  and  then,  the  amount  of  force  employed  should  be 
moderate.  Frequently,  the  sudden  application  to  the  abdomen  of  a 
napkin  wet  with  cold  water,  or  a  sprinkling  of  cold  water  upon  the 
abdomen  and  thighs,  will  excite  the  uterus  to  action. 

So  also  will  coughing,  blowing,  sneezing,  etc.,  or  retching  may  be 
produced  by  titillating  the  throat  and  fauces  with  a  feather.  If  these 
do  not  answer,  Ergot  may  be  administered ;  I  prefer  Lloyd's  Ergot, 
and  it  may  be  administered  in  one-half  to  three-quarters  of  a  tea- 
spoonful  as  a  dose,  repeating  it  every  twenty  or  thirty  minutes,  until 
contractions  are  induced.  Cinnamon  or  Macrotys  will  frequently 
prove  more  advantageous  than  the  Ergot;  Sulphate  of  Quinia,  as  well 
as  Strychnia,  have  frequently  proved  effective  in  these  cases.  After  a 
certain  time,  should  the  above  means  prove  unsuccessful,  it  will  then 
become  necessary  to  pass  up  the  hand  and  extract  the  placenta.  The 
time  necessary  to  elapse  before  attempting  this  manual  operation  is 
generally  stated  at  an  hour,  or  an  hour  and  a  half;  yet  there  can  be 
no  positive  rule,  to  guide  us;  for  instance,  when  the  labor  has  been 
very  tedious  and  severe,  the  uterus  being  sluggish  and  inactive,  with- 
out hemorrhage,  the  operation  may  be  safely  delayed  for  even  a  longer 
period ;  and  in  many  instances  of  this  kind  it  will  be  found  that  the 
placenta  has  been  remaining  nearly  all  the  time  in  the  upper  part  of 
the  vagina ;  consequently,  under  such  circumstances,  it  will  be  well  to 
make  an  exploration  of  the  parts  within  a  half  hour.  It  must  be  re- 
membered, however,  that  the  sooner  after  delivery  the  more  easily  can 
the  hand  be  introduced  into  the  uterine  cavity,  as  the  parts  will  be  in  a 
more  relaxed  condition ;  and  the  manipulation  should  never  be  delayed 
until  the  parts  have  so  far  recovered  their  original  firmness  as  to  render 
the  entrance  of  the  hand  painful  and  difficult.  One  hour  and  a  half,  un- 
der ordinary  circumstances,  or  three  hours  in  cases  of  extremely  tedious 
labor,  nmy,  perhaps,  be  considered  the  limits;  although  I  have,  in  twoin- 
'stances,  readily  introduced  the  hand  within  the  vaginal  and  uterine  cav- 
ities, and  safely  removed  the  placenta,  seven  hours  after  the  birth  of  the 
child;  in  each  case  the  labor  having  been  very  protracted.  The  mode 


526  KING'S  ECLECTIC  OBSTETRICS. 

of  removing  the  placenta  has  already  been  described  under  the  treat- 
ment of  Hemorrhage  during  its  retention. 

Be  extremely  careful  never  to  withdraw  the  hand  from  the  cavity 
of  the  uterus,  holding  the  placenta,  without  first  having  induced  con- 
tractions of  the  organ ;  and  should  these  not  occur,  after  the  placenta 
has  been  detached,  the  hand  must  be  kept  in  the  uterus,  until  they 
have  been  excited  by  some  of  the  various  methods  already  recom- 
mended. And  after  the  mass  has  been  abstracted,  it  should  be  care- 
fully examined  to  ascertain  that  no  portion  of  it  has  been  left 
behind.  The  prudent  introduction  of  the  hand  into  the  womb  for 
the  abstraction  of  the  placenta,  is  always  safer  than  the  attempt  by 
forcible  traction  upon  the  cord.  As  soon  as  the  placental  mass  has 
teen  delivered,  do  not  fail  to  secure  the  permanency  of  the  uterine 
contractions,  by  the  application  of  the  bandage,  and  if  necessary,  a 
compress.  Crude's  method  is  frequently  useful. 

Dr.  Murphy,  in  his  Lectures  on.  Parturition,  observes :  "Retention 
of  the  placenta  may  arise  from  different  causes.  Sometimes  the  sphinc- 
ter of  the  vagina  closes  upon  it,  and  the  placenta  is  thus  retained  until 
removed  by  the  hand,  or  by  firm  pressure  on  the  fundus  of  the  uterus. 
In  other  instances,  the  placenta  remains  in  the  uterus  after  the  delivery 
of  the  child,  until  it  is  expelled  by  its  subsequent  contractions,  ren- 
dered efficient  by  similar  contractions  of  the  diaphragm  and  abdominal 
muscles.  This  additional  aid  is  required,  inasmuch  as  the  action  of 
the  uterus  alone  is  not  sufficient  for  the  purpose.  Hence,  when  the 
abdominal  muscles  are  feeble,  so  that  the  uterus  can  derive  no  support 
from  them,  the  placenta  is  retained  in  this  cavity.  This  cause  of  reten- 
tion has  been  generally  mistaken  for  inertia  of  the  uterus ;  and,  under 
this  impression,  the  placenta  has  been,  very  necessarily,  withdrawn 
from  the  uterine  cavity.  *  *  .*  When  the  child  leaves  the  uterus, 
a  very  powerful  stimulus  to  its  action  is  removed;  and  this  stimulus 
the  placenta  is  quite  inadequate  to  supply.  The  uterus,  therefore,  first 
ceases  to  act  for  a  certain  time,  and  when  the  action  is  renewed,  it  is 
weak,  and  continues  only  for  a  short  time.  If  the  uterus  fails  in  dis- 
charging the  placenta  by  a  few  of  these  efforts,  it  becomes  accustomed, 
as  it  were,  to  its  presence,  and  it  no  longer  acts  as  a  stimulus,  but 
remains  with  the  uterus  imperfectly  contracted  around  it.  A  very 
efficient  means  of  supplying  this  want  of  irritation  to  the  uterus,  is 
the  pressure  of  the  abdominal  viscera  whick  surround  it.  When  the 
abdominal  muscles  are  strong,  they  contract  upon  the  retiring  uterus, 
compressing  the  intestines,  and  consequently  the  uterus,  on  all  sides. 
These  weak  pains,  therefore,  are  greatly  assisted  and  rendered  effectual 


COMPLICATED  LABOR — HOUR-GLASS    CONTRACTION.  527 

by  the  straining  efforts  of  the  patient  acting  as  a  stimulus  to  the  uterus 
from  without.  But  the  abdominal  muscles  are  not  always  strong;  on 
the  contrary,  in  most  instances,  they  are  extremely  weak,  in  conse- 
quence of  our  civilized  habits.  They  are  too  often  reduced  almost  to 
a  state  of  atony  from  the  constant  pressure  of  the  corset;  hence  it 
follows  that  the  uterus  derives  little  or  no  support  from  them,  and  the 
placenta  is  retained,  not  from  any  want  of  power  in  the  uterus  to  expel 
it,  but  from  a  want  of  efficient  stimulus  to  cause  the  uterus  to  contract. 
There  is  no  inertia  of  the  uterus,  but  only  a  suspension  of  its  action. 
It  is  for  this  reason,  and  to  supply  this  deficiency,  that  the  pressure 
of  the  hand  on  the  fundus  of  the  uterus,  during  the  expulsion  of  the 
child,  is  found  so  useful ;  and,  on  the  same  principle,  the  application 
of  a  bandage  round  the  abdomen  is  always  necessary,  in  order  to  give 
it  proper  support." 

2.  IRREGULAR  CONTEACTION  OF  THE  UTERUS,  termed 
Hour-glass  Contraction,  sometimes  accompanies  retained  placenta.  It 
may  affect  any  part  of  the  uterus,  but  is  more  commonly  met  with  at 
the  os  uteri.  True  hour-glass  contraction  is  a  strictured  condition  of 
the  central  portion  of  the  organ,  dividing  it  into  two  chambers,  an 
upper  one,  which  usually  contains  the  placenta,  and  a  lower  one;  it  is 
rarely  met  with  in  practice. 

Sometimes  the  uterus  contracts  longitudinally  upon  the  placenta, 
having  the  shape  of  a  cylinder  or  sugar-loaf;  sometimes,  there  will  be 
a  contraction  of  only  one  corner;  at  others,  it  contracts  upon  the  pla- 
centa in  a  globular  form ;  again,  the  constriction  at  the  center,  forming 
the  true  hour-glass  contraction,  may  be  met  with.  The  placenta  may 
be  completely  inclosed  above  the  strictured  part,  or  only  partially,  part 
of  it  being  in  the  cavity  above  the  contracted  portion  of  the  uterus, 
and  the  remainder  passing  through  the  narrowed  section  into  the 
cavity  below.  The  placenta,  in  these  cases,  may  be  wholly  or  partially 
adherent,  or  it  may  be  detached.  Prof.  Meigs  believes  the  placenta 
to  be  always  adherent  in  hour-glass  contraction ;  Dr.  Douglass,  of 
Dublin,  thinks  it  almost  invariably  occurs  with  morbid  placental  adhe- 
sion ;  so  likewise  does  Dr.  F.  H.  RamsbotKam,  and  in  the  cases  which 
I  have  met  with,  I  have  found  placental  adhesions  to  a  greater  or  less 
extent  in  each  of  them. 

This  irregular  contraction  of  the  uterus  may  exist  in  the  longitudinal 
fibers,  or  in  the  transverse,  and  more  generally  occurs  after  a  rapid 
delivery  by  violent  and  forcible  pains.  It  may,  however,  follow  a 
protracted  or  preternatural  labor,  or  a  delivery  of  the  child  effected 


528  KING'S   KCLECTIC  OHSTKTUICS. 

by  Ergot,  and  sometimes  happens  as  the  result  of  an  over-distended 
uterus.  Not  unfrequently  an  improper  interference  with  the  cord, 
making  traction  in  the  wrong  direction,  and  by  jerks,  instead  of  a 
can- ful,  continuous  pull,  will  irritate  the  os  uteri  and  cause  the 
womb  to  contract  irregularly ;  pressure  and  friction  immediately 
over  the  pubes  instead  of  over  the  fundus  uteri,  has  also  occasioned 
the  difficulty. 

Hemorrhage  may,  or  may  not  be  present;  and  when  it  does  exist  it 
is  generally  less  profuse  and  alarming  than  when  there  is  a  complete 
state  of  inertia,  so  that  less  haste  will  be  required  for  the  extraction 
of  tlie  placenta;  this,  however,  will  be  found  a  more  difficult  and 
dangerous  operation,  than  in  retained  after-birth  without  irregular  or 
spasmodic  contraction. 

DIAGNOSIS. — Most  instances  of  irregular  uterine  contraction  are 
impossible  to  detect  by  external  examination.  Generally,  the  delivery 
of  the  child  is  followed  by  several  severe  and  strong  pains,  without 
any  descent  of  the  placenta,  and  which  symptom,  in  connection  with 
a  hard  and  enlarged  condition  of  the  uterus,  when  felt  through  the 
abdominal  parietes,  and  a  full  and  turgid  state  of  the  umbilical  cord, 
may  lead  to  a  suspicion  of  the  difficulty. 

Should  the  uterus  contract  in  the  cylindrical  form,  it  may  be 
detected  through  the  abdomen,  the  fundus  being  felt  at  the  epigas- 
trium, and  the  body  conveying  to  the  fingers  the  sensation  of  a  roll 
or  cylinder. 

If  it  be  a  true  hour-glass  contraction,  it  may  likewise  be  detected 
by  abdominal  palpation.  The  uterus  will  be  found  to  form  two 
tumors  just  above  the  pubis,  the  larger  one  of  which  contains  the 
placenta,  while  the  smaller  is  joined  to  the  other  by  a  kind  of  neck, 
which  is  the  constricted  central  portion  of  the  uterus. 

But  the  more  positive  method  of  ascertaining  the  difficulty  is  by  an 
examination  per  vaginam.  Passing  the  hand  along  the  cord,  the 
cervix  may  be  found  hard  and  firmly  contracted,  resisting  the  intro- 
duction of  a  finger,  while  the  other  hand  placed  upon  the  abdomen, 
will  find  the  uterine  globe  relaxed,  or  at  all  events,  less  firmly  con- 
densed than  the  cervix.  If  the  constriction  is  not  at  this  point,  the 
hand  must  be  carefully  carried  into  the  uterus,  following  the  cord, 
when  it  will,  at  some  point,  detect  an  aperture  which  leads  into  the 
upper  chamber,  and,  perhaps,  a  portion  of  the  placenta  may  be  felt 
protruding  through  it.  In  this  case,  the  lower  part  of  the  uterus  will 
be  usually  soft  and  flabby  while  the  portion  above  the  stricture  will 
be  harder  and  firmer.  The  accoucheur  must  not  mistake  this  aperture 


COMPLICATED    LABOR — HOUR-GLASS    CONTRACTION.  529 

for  a  rupture  of  the  uterus;  for,  it  must  be  borne  in  mind,  that  while 
the  child  escapes  through  a  rupture,  the  placenta  seldom  does. 

TREATMENT. — This  will  depend  somewhat  upon  the  presence  or 
absence  of  hemorrhage.  If  it  be  present  and  profuse,  the  accoucheur 
will  at  once  attempt  the  extraction  of  the  placenta,  in  the  manner 
described  hereafter;  if  it  be  not  very  profuse  or  alarming,  he  will 
proceed  in  his  management  more  slowly  and  cautiously,  being  gov- 
erned, in  this  respect,  by  the  effects  of  the  loss  of  blood  upon  the 
patient. 

Where  hemorrhage  does  not  exist,  and  the  placenta  does  not  pass 
away,  within  the  ordinary  period,  there  is  no  necessity  for  haste, 
unless,  indeed,  a  true  hour-glass  contraction  be  ascertained,  when 
interference  should  be  promptly  attempted,  there  being,  in  such  case, 
but  a  small  chance  for  the  spontaneous  expulsion  of  the  placenta. 

In  all  other  cases,  where  there  are  no  additional  circumstances 
present  requiring  interference,  attempts  should  not  be  made  to  remove 
the  placenta  artificially,  for  at  least  an  hour  after  the  birth  of  the  child 
The  treatment  employed  in  the  mean  time,  should  be  the  same  as 
already  recommended  in  retention  from  inertia,  as  constant  pressure 
over  the  fund  us,  slight  but  continued  traction  upon  the  cord  in  the 
direction  of  the  axis  of  the  superior  strait,  etc.,  and  which  will 
frequently  subdue  the  spasmodic  action,  and  effect  a  sudden  ejection 
of  the  placenta.  And  if  there  be  much  mental  excitement  on  the 
part  of  the  patient,  this  should  be  allayed  by  some  anodyne.  An  hour 
having  passed  without  indications  of  an  expulsion  of  the  placenta, 
the  manual  operation  will  have  to  be  attempted.  Introduce  the  hand 
into  the  vagina  in  the  usual  way,  and  then  into. the  uterus.  If  the 
constriction  be  at  the  os  cervix,  gently  and  carefully  introduce  first 
one  finger  and  then  another,  until,  if  necessary,  the  whole  hand  has 
entered;  but  frequently,  the^  os  maybe  dilated  with  two  fingers,  so 
that  the  placenta  may  be  seized  and  slowly  worked  out — and,  some- 
times, this  dilatation  alone  will  remove  the  spasm  and  induce  normal 
contractions,  followed  by  a  delivery  of'  the  secundines. 

If  the  contracted  portion  be  higher  up,  the  hand  being  guided  by 
the  cord,  will  have  to  be  passed  upward  until  the  constriction  is 
reached,  and  then,  as  before,  first  one  finger,  then  another  must  be 
introduced,  gradually  and  steadily  dilating  the  strictured  part  as  they 
enter,  until  the  whole  hand  has  been  insinuated;  then,  if  the  placenta 
be  adherent,  it  must  be  carefully  and  entirely  detached,  and  the  hand 
and  secundines  suffered  to  pass  out  by  the  uterine  contractions  only. 
If  the  mass  be  removed  before  the  uterus  acts,  hemorrhage  may  come 


530  KING'S  ECLECTIC  OBSTETRICS. 

on,  hence  it  is  important  to  induce  the  action  of  the  organ  before 
withdrawing  the  hand. 

The  practitioner  must  not  forget,  while  attempting  the  intromission 
of  the  hand  through  the  contracted  aperture  of  the  uterus,  to  place 
his  other  hand  upon  the  abdomen  externally,  and  press  upon  the 
fundus  downward,  in  the  direction  of  the  operating  hand.  If  this  be 
neglected,  the  womb  may  be  so  far  elevated  by  the  hand  within  as  to 
render  it  somewhat  difficult,  if  not  impossible,  to  enter  it.  Sometimes 
the  hand  may  be  readily  passed  beyond  the  contracted  part ;  at  others, 
time,  perseverance,  and  gentleness,  will  be  required  before  the  object 
can  be  accomplished. 

Occasionally  the  contraction  will  be  extraordinarily  firm,  and  if 
dilatation  be  effected,  it  will  be  followed  by  yet  firmer  contraction, 
requiring  so  much  force  to  enable  the  fingers  or  hand  to  enter,  as 
would  be  liable  to  cause  laceration  if  the  attempt  be  imprudently 
persisted  in.  Such  force  must  never  be  employed.  If  the  placenta 
can  not  be  removed  without  violence,  let  it  alone,  and  pursue  the 
course  named  under  the  treatment  of  Morbid  Adhesion.  In  these 
cases  the  uterus  is  usually  in  a  very  irritable  condition. 

Bleeding  has  been  recommended  in  these  instances,  to  effect  relaxation, 
but  it  is  a  very  objectionable  course,  as  it  must  not  only  unnecessarily 
debilitate  the  patient,  but  place  her  life  in  a  very  precarious  situation, 
should  a  profuse  flooding  from  the  uterus  follow  the  relaxation  caused 
by  it. 

Chloroform  has  been  exhibited  in  these  instances,  for  the  purpose 
of  causing  .relaxation,  with  success.  In  some  cases  Gelsemium  or 
Lobelia  give  very  satisfactory  results,  as  does  also  the  compound 
tincture  of  Lobelia  and  Capsicum.  Ergot  has  been  advised,  but,  I 
think,  upon  unsafe  grounds.  As  soon  as  the  moment  of  relaxation 
occurs,  the  hand  should  be  introduced,  and  the  placenta  extracted. 

The  compound  tincture  of  Lobelia  and  Capsicum  may  be  exhibited 
either  by  mouth,  or  by  injection  into  the  rectum.  I  prefer  the  latter 
mode,  which  is  the  one  I  have  used  the  oftenest  and  with  decided  suc- 
cess. The  contents  of  the  rectum  having  been  first  removed  by  an 
enema,  the  above  tincture,  in  the  quantity  of  three  or  four  flui- 
drachms,  may  be  at  once  injected.  It  usually  acts  with  promptness  in 
overcoming  the  spasms,  when  the  hand  should  at  once  be  introduced, 
if  demanded.  If,  as  may  sometimes  be  required,  it  becomes  necessary 
to  give  this  antispasmodic  by  mouth,  one  or  two  fluidrachms  may  be 
taken  for  a  dose.  In  either  case  it  must  not  be  diluted.  It  rarely 
produces  a  degree  of  relaxation  sufficient  to  give  apprehensions  of 


COMPLICATED  LABOR — MORBID  PLACENTA L  RETENTION.   531 

hemorrhage:  generally,  as  soon  as  the  spasm  has  been  overcome  and 
the  secundines  removed,  the  uterus  contracts  regularly  and  perma- 
nently. If  much  relaxation  of  the  system  should  follow  its  use, 
Carbonate  of  Ammonia,  Ether,  or  other  stimulant,  will  speedily  effect 
a  beneficial  change. 

In  the  exhibition  of  this  tincture  per  rectum,  it  will  sometimes  be 
found,  as  I  have  experienced  in  my  own  practice,  as  well  as  ascer- 
tained in  that  of  others,  that  an  introduction  of  the  hand  will  not  be 
needed ;  for  as  the  spasm  is  subdued  the  uterus  will  act  normally,  and 
the  placenta  will  be  expelled  without  any  further  assistance. 

The  Sp.  Tr.  of  Gelsemium,  when  the  parts  are  tense,  hot  and  rigid, 
is  especially  indicated,  and  under  such  circumstances  will,  it  is 
claimed,  produce  complete  relaxation.  That  it  will  effect  the  desired 
dilatation  will  hardly  be  doubted  by  any  one  who  has  ever  used  it; 
but  whether  the  persistency  of  its  relaxing  influence  can  be  promptly 
obviated,  and  a  tendency  to  flooding  thereby  lessened  or  prevented,  I 
am  not,  from  my  own  knowledge  of.  its  use  in  these  cases,  prepared  to 
say,  although,  in  the  absence  of  Chloroform,  I  think  I  should  not 
hesitate  to  administer  it,  using  at  the  same  time,  however,  a  degree  of 
watchfulness  and  prudence. 

When  the  placenta  is  partly  within  the  uterus  and  partly  within  the 
vagina,  the  os  uteri  having  contracted  upon  it,  no  attempts  to  remove 
it  by  forcible  pulling  should  be  made,  as  this  would  be  very  apt  to 
tear  it;  the  only  method  for  its  removal  should  be  a  gentle  dilatation 
of  the  os  by  means  of  the  fingers. 

When  the  placenta  has  been  extracted,  examine  it  carefully,  as  has 
been  heretofore  recommended;  and  do  not  forget  the  necessity  for 
securing  a  regular,  equal,  and  permanent  uterine  contractility. 

For  irregular  pains,  Macrotys  should  probably  be  first  considered ; 
Lobelia  or  Gelsemium  should  be  chosen  if  the  irregularity  is  due  to 
want  of  complete  dilatation;  Sulphate  of  Quinine  will  likewise  over- 
come the  trouble  in  some  cases.  The  Parturient  Balm,  taken  during 
the  last  two  or  three  months  of  gestation,  will  prevent  irregular  action 
of  the  uterus  at  the  time  of  labor. 

3.  PLACEFTAL  RETENTION  from  a  MOKBID  ADHESION 
to  the  UTERUS,  is  sometimes  met  with,  and  is  of  a  more  critical 
nature  than  the  previous  varieties.  It  may  exist  ill  conjunction  with 


532  KINO'S  KCLI-X-TK    onsi  KTUICS. 

irregular  contraction,  or  with  inertia  of  the  uterus,  which  last  renders- 
it  more  formidable,  from  the  dangerous  hemorrhage  apt  to  be  present: 
frequently  a  few  minutes  decide  the  question  of  life  or  death. 

The  adhesion  may  be  complete,  in  which  case  there  will  be  no  flood- 
ing until  detachment  ensues;  or  it  may  be  partial,  and  commonly  with 
hemorrhage.  The  copiousness  of  the  discharge  will  be  in  proportion 
to  the  extent  of  detached  surface,  and  the  number  of  vessels  exposed. 

The  cohesive  energy  existing  between  the  uterus  and  placenta  in 
these  cases,  varies  considerably;  , sometimes,  the  contractions  of  the 
uterus  are  sufficient  to  detach  and  expel  the  mass ;  at  others,  the  uterus 
may  not  be  able  to  cause  its  separation,  which,  however,  may  be  readily 
effected  by  the  hand;  again,  the  cohesion  may  be  so  great,  as  to  resist 
any  justifiable  attempts  to  remove  it  with  the  hand.  And,  instances 
have  occurred  where,  after  death,  the  separation  could  not  be  accom- 
plished by  maceration,  and  also  where  it  was  impossible  to  distinguish 
the  line  of  demarcation  between  the  uterus  and  placenta  when  a  longi- 
tudinal section  of  these  organs  had  been  made. 

The  causes  of  morbid  placental  adhesion  are  not  satisfactorily 
known.  By  some  authors  the  difficulty  is  attributed  to  a  deposition 
of  calcareous  or  tuberculous  matter,  from  the  fact,  that  these  have  been 
found  in  some  portion  of  the  placenta,  usually  on  its  maternal  surface. 
Again,  it  is  believed  by  others,  that  whenever,  from  any  cause  during 
gestation,  an  excitement  or  inflammation  of  the  placenta  or  uterus  is 
produced,  it  may  result  in  an  effusion  of  lymph,  perhaps,  forming  a 
new  membrane,  which  more  firmly  consolidates  the  utero-placental 
attachment.  But,  whatever,  may  be  imagined  on  this  point,  it  is 
evident  that  morbid  adhesion  occurs  altogether  independent  of  the 
character  or  management  of  labor,  and  is  due  entirely  to  abnormal 
conditions,  either  of  the  placenta,  or  of  the  uterus,  during  pregnancy. 
It  is  very  apt  to  recur  in  the  same  woman,  so  that  when  called  to 
attend  such  cases  (when  known)  the  physician  should  be  more  prompt 
in  his  movements  than  in  ordinary  instances. 

DIAGNOSIS. — We  can  know  nothing  whatever  of  a  morbid  adhe- 
sion, until  the  hand  is  introduced  for  the  purpose  of  extraction.  It 
may  be  suspected,  however,  when  several  strong  pains  occur,  without 
any  loosening  of  the  placenta;  likewise,  when  the  cord,  being  moder- 
ately drawn  upon  and  then  suddenly  let  loose,  springs  upward  with  a 
jerk.  Sometimes  the  patient,  during  gestation,  complains  of  a  severe, 
persistent  pain  at  one  particular  point  (that  in  which  the  placenta  is 
found  attached),  and  may  express  her  suspicions  that  "the  after-birth 
is  growing  fast  to  her  side." 


COMPLICATED  LABOR — MORBID  PLACENTAL  RETENTION.   533 

TREATMENT. — When  hemorrhage  is  present,  the  case  must  be 
managed  as  described  under  Hemorrhage  with  Retention  of  the 
Placenta.  Hemorrhage  requires  the  detachment  and  removal  of  the 
placenta,  or  the  patient  will  almost  certainly  die.  If  no  hemor- 
rhage exist,  the  adhesion  will  be,  probably,  entire. 

The  early  treatment  of  this  difficulty,  will  be  similar  to  that  advised 
in  the  preceding  varieties — not  knowing  its  true  character.  This 
failing,  and  an  hour  having  elapsed,  the  hand  must  be  introduced,  in  the 
manner  heretofore  explained,  to  effect  the  detachment,  at  which  time 
the  nature  of  the  adhesion  will  be  ascertained.  The  placenta  should 
be  removed,  if  possible,  even  at  the  expense  of  considerable  trouble  ; 
but  sometimes,  its  detachment  will  be  impossible. 

In  these  latter  cases,  there  is  a  diversity  of  opinion  as  to  the  proper 
course  to  be  pursued,  many  eminent  accoucheurs  advise  us  to  remove 
as  much  of  the  placenta  as  we  can,  even  if  it  have  to  be  separated  in 
pieces  to  accomplish  this  result ;  while  others,  recommend  us  to  leave 
the  mass  in  the  uterus,  until  decomposition  has  ensued,  and  then 
attempt  its  removal,  or  if  this  can  not  be  done,  trust  to  the  natural 
powers,  aided  by  means  to  overcome  the  evil  results  of  putrefactive 
absorption. 

When  the  placenta  can  be  removed  without  any  great  violence,  it 
should  always  be  effected  ;  but,  if  the  reverse  of  this  obtains,  I  think 
I  am  warranted  by  my  own  experience,  in  connection  with  that  of 
many  others,  in  recommending  it  to  be  left  until  decomposition  ensues, 
when  a  safer  opportunity  for  its  extraction  may  be  offered.  The  tend- 
ency to  hemorrhage  will  be  less  when  the  whole  mass  is  thus  left 
behind,  than  when  a  portion  .of  it  has  been  torn  off  and  removed,  the 
rest  remaining  adherent.  These  entire  and  extremely  tenacious  adhe- 
sions are  fortunately  quite  rare. 

In  these  several  instances  of  retained  placenta,  no  attempts  should 
ever  be  made  to  remove  it  by  forcibly  pulling  upon  the  cord  ;  neither 
should  the  placenta  itself,  provided  a  part  of  it  can  be  seized,  be 
drawn  upon,  until  it  has  been  satisfactorily  ascertained  that  it  is  per- 
fectly loose,  and  that  no  portion  of  it  is  retained  in  a  firmly  contracted 
os  uteri.  Otherwise,  an  inversion  of  the  uterus  may  be  produced,  or, 
the  placenta  may  be  torn,  and  the  remaining  adherent  portion  of  it 
within  the  uterus,  occasion  a  subsequent  hemorrhage. 

Should  the  UMBILICAL  CORD  BE  RUPTURED,  then,  after  a 
failure  of  the  means  heretofore  recommended  for  procuring  uterine 
contractions,  the  hand  must  be  very  carefully  and  gently  introduced 
within  the  uterus,  the  placenta  sought  for,  detached,  and  removed  in 


534  KING'S  ECLECTIC  <>I;STKTJJICS. 

the  usual  manner,  being  particular  to  remove  it  entire,  in  order  to> 
avoid  an  attack  of  flooding. 

When  the  placenta  is  so  FIRMLY  RETAINED  by  THE  IRREG- 
ULAR CONTRACTION  OF  THE  UTERUS,  or  by  MORBID 
ADHESION,  as  to  resist  all  legitimate  endeavors  to  remove  it,  or 
when  portions  of  it  have  been  permitted  to  remain  in  the  uterine 
cavity,  the  mode  of  treatment  will  depend  somewhat  upon  the  symp- 
toms which  follow. 

Generally,  severe  after-pains  are  experienced,  which  interfering  with 
the  patient's  sleep  and  quiet,  render  her  very  irritable — and  these  pains 
are  augmented  on  pressure  over  the  uterine  tumour,  or  when  the  child 
is  applied  to  the  breast.  The  discharge  from  the  uterus  is  at  first  of  a 
normal  amount,  and  clots  are  occasionally  passed  off  with  it;  but  in  two 
or  three  days  its  .character  changes,  becoming  of  a  dark  brownish  color, 
excessively  fetid,  and  accompanied  with  pieces  of  the  decomposed 
placenta.  This  happens,  more  especially,  when  only  a  portion  of  the 
mass  is  left  behind. 

Soon  after  putrescency  has  commenced,  from  (septicaemia)  an  absorp- 
tion of  the  putrid  animal  matter,  a  severe  irritative  fever  attacks  the 
patient,  manifesting  itself  at  first  by  rigors.  The  pulse  becomes  small 
and  rapid,  the  skin,  and  especially  that  on  the  abdomen,  becomes  hot 
and  dry,  pain  in  the  head,  of  a  diversified  character  comes  on — it  may 
be  continuous,  and  accompanied  with  beating  or  throbbing,  or,  it  may 
be  intermittent,  sharp,  and  darting.  The  tongue  is  at  first  white,  and 
slimy,  or  red,  shining,  and  dry;  the  thirst  is  inordinate;  vomiting  is 
frequently  present,  or  a  choking  sensation,  particularly  when  the  patient 
endeavors  to  drink ;  there  is  constant  restlessness  and  wakefulness,  with 
mental  anxiety,  which  is  plainly  depicted  upon  the  countenance.  The 
secretion  of  milk  diminishes ;  the  bowels,  at  first  very  torpid,  become 
so  excessively  loose  as  to  resist  the  attempts  made  to  check  their  action. 
Most  usually,  erratic  pains,  of  greater  or  less  severity,  are  present, 
shooting  from  one  hip  to  the  other,  perhaps  locating  in  the  neighbor- 
hood of  the  diaphragm  and  interfering  with  respiration,  or,  shifting 
from  one  part  of  the  body  to  another.  These  symptoms  continue  t& 
increase,  the  tongue  becomes  coated  brown  or  black,  the  abdomen 
becomes  tumid  and  tense,  the  strength  rapidly  fails,  the  extremities 
become  cold,  vomiting  of  a  dark-brownish  granular-like  substance 
occurs,  with  low  delirium,  involuntary  evacuations  of  the  feces  and 
urine,  subsultus  tendinum,  and  iu  ten  or  twelve  days  following: 
delivery,  the  case  terminates  fatally. 


COMPLICATED  LABOR — RETENTION  OF  THE  PLACENTA,  ETC.  535 

Ramsbotham  states,  that  "  upon  dissection,  the  veins  of  the  uterus 
are  generally  found  inflamed,  and  containing  pus;  the  uterus  itself,  to 
a  greater  or  less  extent,  partakes  in  the  inflammatory  disposition,  and 
is  perhaps  gangrenous;  or  purulent  deposits  are  observed  in  its  sub- 
stance; and  perhaps  also  in  or  around  some  of  the  larger  joints,  or 
among  the  tendons,  or  within  the  fleshy  muscles  of  the  limbs." 

Sometimes,  the  placenta  is  expelled  in  twelve  or  twenty-four  hours 
without  putrefaction,  or  any  unpleasant  consequences ;  at  others,  it  has 
been  expelled  in  a  putrescent  condition,  but  without  causing  any  irri- 
tative fever;  and  again,  in  some  rare  cases,  it  has  never  been  discharged 
nor  produced  any  injury  to  the  general  health,  but  has,  as  supposed  by 
some  writers,  either  been  absorbed,  or  continuing  adherent,  become 
organized. 

A  very  favorable  indication  when  putrid  absorption  takes  place,  is, 
to  observe  that  the  symptoms  are  less  violent,  and  the  discharge  of  a 
puriform  character,  containing  portions  of  the  placenta,  having  but 
little  or  no  fetor,  and  accompanied  by  no  great  amount  of  prostration 
of  the  vital  powers. 

TREATMENT. — "When  it  is  ascertained  that  the  placenta  can  not 
be  removed,  a  bandage  should  be  applied  around  the  body,  in  the 
manner  heretofore  indicated,  with  a  compress  over  the  fundus,  and  in 
two  or  three  days  the  attempts  to  abstract  the  mass  should  be  cautiously 
and  gently  renewed.  However,  should  the  pains  at  any  time  become 
very  severe  and  continuous,  or  the  presence  of  the  bandage  appear  to 
increase  them,  it  must  be  removed. 

When  the  placental  mass  can  not  be  artificially  abstracted,  or  when 
portions  of  it  have  been  left  adhering  to  the  inner  uterine  wall,  and, 
in  either  case,  putrescency  occurs,  the  indications  of  treatment  will  be, 
to  subdue  inflammation,  correct  the  fetor  of  the  discharge,  and  support 
the  vital  powers:  and  for  the  fulfillment  of  these,  various  remedies 
may  be  used. 

When  there  is  hemorrhage,  it  must  be  combated  by  the  means 
already  indicated.  When  the  fever  is  very  high,  with  great  irritability 
of  the  system,  to  subdue  it  and  neutralize  to  a  greater  or  less  extent 
the  influence  of  the  absorbed  matter,  the  proper  sedative  should  fir>t 
be  selected;  this  will  be  either  Aconite  or  Veratrum.  In  addition, 
agents  should  be  selected  to  prevent  the  absorption  of  putrid  matter 
and  the  development  of  septicaemia,  as  Chlorate  of  Potassium,  Phyto- 
lacca,  Baptisia,  Asepsin,  Quinine,  etc.  Vaginal  injections  should 
likewise  be  used  in  conjunction  with  internal  treatment,  as  will  be 
noticed  in  the  following  page.  When  the  influence  of  these  agents  is 


536  KIND'S    KCLECTIC    OBSTETRICS. 

once  obtained,  by  continuing  it,  together  with  the  other  means  to 
combat  putrescency,  the  tendency  to  vomiting  will  be  considerably 
lessened.  Should  there  be  a  great  amount  of  pain,  it  may  become 
necessary  to  administer  a  small  dose  of  Morphia,  in  conjunction  with 
the  means  heretofore  recommended.  The  bowels  should  be  kept  free 
by  Seidlitz  powders  and  mucilaginous,  laxative  injections ;  and  when 
they  become  immoderately  loose,  the  tincture  of  Chloride  of  Iron  may 
be  given  in  doses  of  ten  or  twenty  drops  in  sufficient  water,  and 
repeated  according  to  the  urgency  of  the  case;  or  teaspoon ful  doses 
of  Liquor  Bismuth,  repeated  every  three  hours,  will  act  very  kindly. 

The  surface  should  be  frequently  bathed  with  warm  water,  or  an 
acidulous  solution.  In  some  instances  a  warm  saline  solution  will  be 
found  more  efficacious. 

To  overcome  the  fetor,  and  aid  in  removing  the  loosened  putrid 
portions,  water,  as  hot  as  the  patient  can  endure,  in  which  is  dissolved 
either  Borax,  Chlorate  of  Potassium,  Asepsin,  Carbolic  Acid,  Per- 
manganate of  Potassium,  or  some  efficient  antiseptic  should  be  injected 
into  the  vagina  and  uterus;  this  should  be  repeated  at  least  twice  a 
day.  The  ports  should  likewise  be  washed  out  with  the  plain  hot 
water  injections  sufficiently  often  to  overcome  the  odor  of  decomposi- 
tion. Too  much  force  must  not  be  applied  in  introducing  the  fluids 
into  the  uterus,  lest  they  be  passed  into  the  canal  of  the  Fallopian 
tubes. 

As  soon  as  symptoms  of  prostration  manifest  themselves,  the  above 
internal  treatment  must  be  changed.  To  overcome  the  depressing 
influences  of  the  absorbed  putrescency,  brewer's  yeast  may  be  given 
internally,  ale  or  porter  may  also  be  allowed,  and  good  cider  will  be 
found  a  most  salutary  and  refreshing  draught;  it  may  be  exhibited 
frequently.  And  in  the  absence  of  these,  an  endeavor  should  be  made 
to  sustain  the  system  by  Wine,  Ether,  Ammonia,  aromatics,  etc. 

In  conjunction  with  these,  some  preparation  of  Peruvian  bark  or 
Quinia  must  be  given.  The  Sulphites  of  Soda,  Lime,  or  Magnesia, 
have  also  been  advised.  Various  other  agents  may  also  be  used, 
combined  to  suit  the  indications,  as  well  as  views,  of  the  practitioner. 
The  female  should  be  kept  cleanly,  and  the  apartment  which  she 
occupies  be  well  ventilated,  and  maintained  at  a  moderate  temperature. 


COMPLICATED    LABOR INVERSION    OF    THE    UTERUS.  537 


CHAPTER    XL. 

COMPLICATED    LABOR INVERSION    OF    THE    UTERUS — RUPTURE    OF 

THE    UTERUS — RUPTURE    OF    THE    VAGINA — RUPTURE    OF 
THE    BLADDER SYNCOPE— THROMBUS. 

WHEN  attempts  are  made  to  abstract  the  placenta  by  forcibly  pull- 
ing upon  the  cord,  and  especially  if  these  be  made  when  the  uterus  is 
in  a  flaccid  condition,  the  cord  may  be  broken,  or  the  uterus  may  be 
inverted.  INVERSION  OF  THE  UTERUS  may  likewise  be  occa- 
sioned by  a  rude  attempt  to  effect  a  removal  by  pulling  upon  the 
placenta  itself.  It  may  also  be  owing  to  a  rapid  delivery  in  a  large 
pelvis;  to  a  short  umbilical  cord;  to  delivery  taking  place  when  the 
female  is  in  the  erect  posture  ;  to  violent  straining  during  the  last  pains 
of  the  second  stage ;  and  it  is  stated  to  have  occurred  spontaneously, 
or  without  any  satisfactory  causes;  but,  by  far  the  majority  of  inverted 
uteri  are  caused  by  irregular  and  violent  uterine  action.  Improper 
management  of  the  accoucheur  may  bring  it  on,  but,"  generally,  only 
in  those  cases  in  which  the  uterus  is  disposed  to  active  and  irregular 
contractions.  It  has  occurred  spontaneously  after  the  mother's  death, 
and  has  likewise  been  observed  in  the  unimpregnated  and  virgin 
uterus. 

This  accident  may  occur  immediately  after  delivery,  when  it  is 
termed  acute  or  reducible  inversion ;  it  may  not  take  place  for  a  few 
days  after,  in  which  cases,  however,  it  is  stated  that  a  depression  of  the 
fundus  existed  from  the  first;  or,  it  may  happen  gradually,  in  which 
case,  as  well  as  when  the  acute  form  has  not  been  removed,  it  is  called 
chronic  or  irreducible  inversion.  Sometimes  it  takes  place  in  the  unim- 
pregnated uterus,  being  occasioned  by  the  presence  of  a  tumor,  the 
growth  of  which  enlarges  the  organ,  until  its  weight  carries  it  through 
the  os  with  the  fundue  attached  to  it. 

An  inversion  of  the  uterus  is  one  of  the  most  serious  accidents  that 
can  befall  the  parturient  female.  About  one-third  of  the  cases  prove 
fatal,  either  in  a  very  short  time,  or  within  a  month  after  its  occurrence. 
Of  one  hundred  and  nine  fatal  cases  recorded,  seventy-two  died  in  a 
few  hours ;  eight  in  from  one  to  seven  days ;  six  in  from  one  to  four 
weeks  :  or  eighty-six  in  one  month. 

SYMPTOMS. — The  inversion  may  be  partial  or  complete.  When 
it  is  partial,  a  portion  of  the  uterine  wall,  but  more  commonly  the 


538  KING'S  ECLECTIC  OBSTETRICS. 

fuiulus,  is  depressed  within  the  uterine  cavity,  presenting,  internally, 
a  convex  surface.  This  form  may  prove  fatal.  It  can  be  detected 
only  by  introducing  one  or  more  fingers  within  the  uterus,  which  will 
discover  the  convexity  of  the  depressed  part;  also  by  external  palpa- 
tion, which  will,  if  the  depressed  portion  be  situated  anteriorly, 
discover  the  concavity  formed  by  it,  instead  of  the  usual  globular 
form  of  the  womb.  It  is  apt  to  induce  violent  straining  and  bearing- 
down  efforts,  a  tenesmus,  which  may  eventually  occasion  a  complete 
inversion ;  and  which  efforts,  to  any  great  extent,  should  always  be 
prohibited,  after  the  birth  of  the  child,  especially  when  the  uterus  is 
in  a  non-contracted  condition.  There  may  be  no  pains  with  it,  but 
a  sensation  of  sinking.  Hemorrhage  usually  accompanies  it,  and  in 
cases  where  this  is  obstinate  and  long-continued,  it  may  be  owing  to  a 
depression  of  the  above  character,  and  should  be  ascertained  by  passing 
one  or  two  fingers  within  the  uterine  cavity. 

Again,  in  a  partial  inversion,  the  advance  or  depression  of  the 
fundus  may  be  so  extensive  as  to  be  grasped  by  the  inferior  part  of  the 
uterus,  or  even  pass  through  the  os  uteri,  but  without  changing  the 
situation  of  the  cervix.  In  this  case  the  palpation  will  discover  a 
greater  amount  of  concavity,  or  perhaps  a  vacuity  above  the  pubes, 
and  the  finger  will  detect  the  fundus  filling  the  lower  part  of  the 
uterus,  feeling  like  an  elastic  tumor,  more  or  less  painful,  or  it  may  be 
felt  protruding  through  the  os  into  the  vagina,  being  soft  and  convex, 
and  the  hand,  by  being  passed  up,  can  recognize  the  encircling  cervix. 
The  pulse  will  become  small,  rapid,  and  fluttering,  with  sudden  pros- 
tration or  sinking  of  the  vital  energies,  which  happens  independent  of 
any  hemorrhage ;  also  paleness  of  the  countenance,  nausea,  vomiting, 
and  violent  bearing-down  efforts.  The  presence  of  flooding  increase*? 
the  danger. 

In  complete  inversion,  the  cervix,  as  well  as  the  whole  body,  is 
inverted;  the  uterus  is  completely  turned  inside  out;  it  maybe  re- 
tained within  the  labia,  but  more  generally  a  greater  or  less  proportion 
of  it  will  be  found  externally,  from  an  accompanying  prolapse  and 
inversion  of  the  vagina.  Sudden  hemorrhage  and  sinking  occurs, 
with  a  sensation  of  fullness  in  the  vagina,  and  frequently  death  super- 
venes, before  the  practitioner  is  aware  of  the  accident,  from  the  shock 
to  the  nervous  system,  resulting  from  strangulation  of  the  fundus. 
If  this  does  not  take  place  immediately,  all  the  symptoms  above 
enumerated  exist  in  a  greater  degree.  Should  the  uterus  contract, 
hemorrhage  will,  probably,  be  absent. 


COMPLICATED    LABOR — INVERSION    OF   THE    UTERUS.  539 

"  It  will  sometimes  happen  that,  for  hours  after  the  accident,  not  a 
single  pressing  symptom  shall  occur.  In  general,  however,  when  a 
womb  is  left  in  the  inverted  position,  the  patient  is  still  liable  for 
hours,  and  days  afterward,  to  large  and  even  fatal  eruptions  of  blood, 
of  which  I  have  myself  been  a  witness ;  add  to  which,  that  independ- 
ently of  the  flooding,  mere  displacement  of  the  parts  may,  perhaps, 
give  rise  to  more  or  less  collapse ;  obstruction  of  the  bladder,  too,  is 
not  unfrequent,  and  the  introduction  of  the  catheter  may  become 
necessary."  (Blundell.} 

DIAGNOSIS. —  Great  care  must  be  taken  not  to  confound  an 
inverted  uterus  with  some  other  difficulty.  It  has  been  mistaken  for 
a  head,  or  a  breech  presentation  of  another  child,  for  a  placenta,  a 
polypus,  a  mole,  a  clot,  an  excrescence,  etc.;  and  instances  are  not 
wanting,  where  the  uterus,  mistaken  for  something  else,  has  been  torn 
from  the  female  by  an  ignorant  practitioner,  occasioning  the  most 
agonizing  torture,  followed  by  a  rapidly  fatal  termination. 

In  connection  with  the  symptoms  and  examinations  named  above, 
the  uterus  will  be  recognized,  \vhen  its  inversion  is  complete,  by  its 
rough,  flocculent,  and  bleeding  surface,  and  by  its  size  and  shape.  If 
it  can  be  inspected  visually,  the  fibrous  tumor  will  be  of  a  red  color, 
but  which  gradually  changes  to  a  dull  brown  when  the  difficulty 
becomes  permanent.  Upon  abdominal  palpation,  the  uterine  fundus 
is  not  to  be  felt,  and  on  attempting  to  pass  the  sound  into  the  uterine 
cavity,  the  os  and  canal  of  the  cervix  will  not  be  found.  The  inver- 
sion usually  occurs  shortly  after  the  expulsion  of  the  fetus,  and  may 
occur  with  or  without  attachment  of  the  placenta. 

PROGNOSIS. — Those  cases  which  occur  spontaneously  #re  said  to- 
be  more  hazardous  than  those  occasioned  by  traction  of  the  cord  ;  and 
the  rapid  attack  of  the  inversion,  accompanied  with  uterine  inertia, 
greatly  augments  the  danger.  The  more  incomplete  the  extent  of  the 
inversion,  and  the  more  slowly  it  occurs,  the  more  favorable  will  it  be 
for  the  patient.  Again,  the  sooner  the  reduction  of  the  inversion  is 
effected  the  better;  delay  augments  the  difficulties  attending  the 
operation. 

Usually,  the  hemorrhage,  or  the  severe  shock  upon  the  nervous 
system  occasions  the  death  of  the  patient.  Sometimes  the  inverted 
organ  becomes  inflamed,  and,  being  strangulated  by  the  contraction 
of  the  cervix,  gangrene  and  sloughing  ensue,  followed  by  death  ; 
cases,  however,  have  been  recorded  where  such  a  condition  has  termi- 
nated favorably.  Again,  when  patients  have  passed  safely  through 


540  KING'S  ECLECTIC  OBSTETRICS. 

the  early  period  of  inversion,  they  have  been  known  to  live  for  many 
years,  without  its  occasioning  them  much  annoyance  ;  of  course,  in 
these  instances,  the  organ  very  much  diminishes  in  size.  Occasionally, 
the  tumor  becomes  attacked  by  some  malignant  form  of  disease. 

Spontaneous  reduction  of  partial  inversions,  as  well  as  of  chronic 
inversions,  are  recorded  to  have  been  met  with.  A  ready  reduction 
of  acute  cases  is  not  always  successful,  as  the  patient  may  have  been 
too  much  exhausted  before  it  was  accomplished  ;  or,  it  may  be  followed 
after  a  few  days,  or  even  months,  by  death,  the  consequence  of  the 
violence  which  the  uterus  has  suffered.  Generally,  in  these  latter 
instances,  the  danger  returns  with  the  catamenia. 

TREATMENT. — In  partial  or  incomplete  inversion,  two  or  three 
fingers,  or  the  whole  hand,  if  necessary,  may  be  introduced  within 
the  uterine  cavity,  and  the  depressed  portion  be  gradually,  but  con- 
tinuously pushed  upward.  When  the  reduction  is  finished,  provided 
the  wrhole  hand  has  been  introduced,  it  should  not  be  removed  until 
contractions  have  taken  .place,  or  else,  the  inversion  may  be  renewed, 
or,  hemorrhage  ensue. 

When  the  inversion  is  complete,  its  reduction  should  be  attempted 
without  delay,  because,  the  longer  it  remains  without  re-position,  the 
more  difficult  will  be  the  operation,  from  the  continued  contraction 
of  the  os  uteri,  which,  by  impeding  the  circulation,  causes  the  uterine 
tumor  to  enlarge.  A  delay  of  an  hour  or  two  may  render,  any  suc- 
cessful endeavors  impossible  ;  and  its  continuance  for  one  or  two 
days,  generally  renders  it  irreducible.  However,  a  few  rare  cases  are 
recorded  in  which  re-position  was  effected  after  eleven  weeks  had 
transpired,  .and  one  of  sixty-six  weeks  ;  but  such  cases  are  exceptions, 
and  should  never  be  anticipated.  Spontaneous  reduction  of  chronic 
inversion  has  been  noticed  by  several  writers. 

In  effecting  the  reduction,  it  will  be  found  that  it  can  be  accom- 
plished with  greater  facility,  the  sooner  it  is  undertaken  after  the 
occurrence  of  the  accident.  There  are  several  modes  advised  for  the 
operation.  One  is,  after  anointing  the  hands  thoroughly  with  lard, 
vaseline  or  sweet  oil,  to  grasp  the  uterus  with  both  hands,  lessening 
its  bulk  by  compression,  and  steadily  pressing  upward,  so  that  the 
mouth,  then  the  cervix,  the  body,  and  the  fundus,  successively  pass 
into  their  natural  positions;  this,  however,  is  rather  a  difficult 
method,  as  the  pressure  exerted  upon  the  organ  by  the  hands  will  be 
very  apt  to  occasion  contractions,  during  which  all  attempts  will  be 
futile. 


COMPLICATED    LABOR — INVERSION    OF    THE    UTERUS.  541 

Another  method  is,  to  firmly  press  the  back  of  the  fingers  against 
the  fundus,  the  hand  being  held  in  a  half-closed  condition,  and  effect 
the  replacement  in  this  manner,  which  usually  takes  place  with  a  jerk. 

But,  probably,  the  best  mode  is,  to  place  the  fingers  in  a  conical 
form,  press  them,  thus  closed,  upon  the  fundus,  indent  it;  and  carry  it 
upward  through  the  os  uteri,  the  body  and  neck  necessarily  follow- 
ing.— Of  course,  the  practitioner  will  decide  which  course  to  pursue 
according  to  the  conditions  present. 

Several  points,  however,  are  necessary  to  be  attended  to.  The 
female,  if  not  too  much  exhausted,  must  be  placed  on  her  back,  with 
the  hips  considerably  elevated  above  the  chest  (though  when  the 
reduction  is  attempted  immediately  after  the  inversion,  this  is  not  so 
essential),  and  the  legs  and  thighs  flexed  and  separated.  The  hand  to 
be  employed  should  be  well  oiled,  and  the  operation  should  not  be 
undertaken,  nor  persisted  in,  while  the  organ  contracts,  but  only 
during  its  state  of  softness  and  relaxation.  Before  attempting  the 
indentation  of  the  fundus,  the  inverted  organ  must  first,  if  possible, 
be  pushed  up  beyond  the  vaginal  orifice,  and  no  effect  will  be  pro- 
duced until  the  upward  pressure  shall  have  caused  some  extension  of 
the  vagina.  The  pressure  should  not  be  made  against  the  pubic  arch, 
but  in  the  direction  of  the  axis  of  the  pelvic  cavity,  and  to  corres- 
pond as  nearly  as  possible  with  its  center ;  the  practitioner  must  not 
forget  the  direction  of  the  axes  of  the  straits  and  pelvis  during  the 
operation,  as  this  will  only  be  successful  by  carrying  the  fundus  up- 
ward in  their  line.  Should  the  perineum  interfere  with  the  operation, 
press  it  backward  while  passing  the  organ  by  it.  The  pressure  should 
be  firm  and  continuous,  making  no  effort  when  the  uterus  contracts, 
except  that  of  securing  what  has  been  gained,  by  resisting  any  ten- 
dency toward  a  return  to  its  first  misplaced  condition.  Most  commonly 
the  fundus  returns  to  its  normal  situation,  by  a  sudden  jerk,  or  start, 
somewhat  like  a  gum-elastic  bottle  when  turned  inside  out.  Too 
much  force  should  never  be  employed  in  the  operation,  lest  the  uterus 
or  vagina  be  lacerated  ;  a  moderate  force,  steadily  persisted  in,  will 
prove  the  safest  and  most  successful.  Whatever  may  be  the  extent  of 
the  inversion,  after  its  reduction,  the  hand  being  writhin  the  uterine 
cavity,  should  be  retained  there  until  the  contractions  of  the  organ 
expel  it,  using  means  to  forward  these  if  required  ;  and  be  certain  that 
the  restoration  is  complete  before  allowing  the  hand  to  be  expelled. 
A  depression  of  the  fundus  remaining,  may  occasion  violent  bearing- 
down  efforts,  followed  by  a  return,  and  perhaps  an  irreducible  state, 


>1-  KING'S    ECLECTIC    ORSTETRICS. 

of  the  inversion.  A  case  is  recorded  in  which  the  inversion  was 
repeated  three  times,  immediately  following  each  replacement ;  and 
finally  by  holding  up  the  fimdns  with  the  hand  externally,  filling  the 
uterine  cavity  with  lumps  of  ice,  and  giving  ergot,  the  accoucheur  suc- 
ceeded in  securing  firm  contraction,  and  the  patient  recovered.  In  a 
•case  of  this  kind  to  overcome  the  violent  and  irregular  action  of  the 
uterus,  I  should  either  administer  the  compound  tincture  of  Lobelia 
and  Capsicum,  or,  alternate  Gelsemium  with  Aconite,  or  with  Sul- 
phate of  Quinine. 

The  inversion  may  happen  with  complete  detachment  of  the  pla- 
centa, or  it  may  be  more  or  less  adherent.  When  adherent,  there  is  a 
diversity  of  opinion  as  to  the  management,  some  recommending  it  to 
be  removed,  before  proceeding  with  the  re-position,  and  others 
advising  us  not  to  remove  it,  until  the  restoration  has  been  completely 
•established. 

When  the  uterus  is  in  a  relaxed  state,  and  the  placenta  is  completely 
adherent,  or  nearly  so,  to  remove  it  would  be  very  apt  to  cause  a 
hemorrhage  which  might  prove  suddenly  fatal;  or  uterine  contractions 
might  follow  the  detachment,  rendering  a  reduction  of  the  inversion 
very  difficult,  or  altogether  impossible;  hence,  in  such  cases,  it  were 
better  to  return  the  placenta  with  the  uterus,  before  detaching  it,  if 
this  can  be  done,  and  then  to  treat  the  case  as  a  retained  placenta. 

When  the  placenta  is  detached  to  a  considerable  extent,  and  the 
remaining  adkesiorts  can  be  readily  separated,  it  may  be  proper  to 
attempt  this  previous  to  the  reduction ;.  unless  the  hemorrhage  from 
the  vessels  already  exposed  be  very  profuse,  when  the  safest  course 
would  be  to  abstract  the  cake  only  after  the  replacement  of  the  uterus. 
A  slight  and  easily-separated  adhesion,  can  not  seriously  augment 
the  flooding,  hence,  its  removal  should  be  accomplished  before  the 
operation. 

There  may  be  cases  in  which  it  will  be  impossible  to  return  the 
uterus  while  the  placenta  adheres,  and  here  the  difficulty  will  be  very 
great;  a  detachment  of  it  may  be  followed  by  dangerous  hemorrhage, 
or  by  contractions  which  will  interfere  with  the  success  of  the  oper- 
ation. The  case  is  necessarily  one  of  danger,  shall  we  increase  the 
risks  by  removing  the  placenta?  Perhaps  it  may  be  a  better  course 
than  to  run  the  chances  of  a  chronic  inversion.  lean  not  speak  from 
experience ;  but  whichever  course  is  adopted,  be  certain  that  the 
reduction  is  impossible,  by  a  persevering  effort,  and  that  the  obstacle 
is  the  presence  of  the  placenta,  and  not  improper  or  badly-directed 


COMPLICATED    LABOR — INVERSION    OF    THE    UTERUS.  543 

efforts.  Several  writers  state,  that  in  such  cases,  they  have  detached 
the  placenta  without  any  subsequent  bad  results;  while  others,  strongly 
advise  its  removal  in  all  cases  previous  to  attempting  reduction  of  the 
inversion. 

Exhaustion  and  depression  of  the  vital  energies  must  be  combated 
by  stimuli  and  appropriate  treatment,  similar  to  that  laid  down  when 
speaking  of  hemorrhage.  The  female  should  not  be  allowed  to  get 
up  too  soon  after  the  reduction,  keeping  her  in  a  horizontal  position, 
with  the  head  depressed  and  the  hips  considerably  elevated,  the  knees 
and  thighs  being  bent,  and  all  strainings  at  stool  or  bearing-down 
efforts,  should  be  forbidden;  the  bowels  should  be  kept  free  by  mild 
laxatives  or  injections. 

When  the  uterus  has  once  been  inverted  during  a  labor,  it  has  a 
strong  disposition  to  renewal  of  the  difficulty  in  consecutive  ones; 
therefore,  with  such  patients  it  will  be  improper  to  make  any  tractions 
upon  the  cord  to  abstract  the  placenta ;  if  pressure  upon  the  fundus 
with  frictions  will  not  expel  it,  the  best  course  will  be  to  introduce 
the  hand  within  the  cavity  of  the  uterus,  and  remove  the  mass  in  the 
manner  heretofore  explained. 

If  the  inversion  has  been  of  several  days'  standing,  it  has  been 
advised  not  to  omit  attempts  at  the  reduction,  from  the  fact  that  it  has 
b6en  reduced,  in  many  instances,  after  a  lapse  of  weeks  and  even 
months.  But  in  these  cases,  from  the  long-continued  strangulation, 
the  uterus  becomes  swollen,  and  the  parts  hot  and  dry— therefore, 
before  operating,  these  conditions  must  be  overcome  by  anodyne  and 
relaxing  fomentations  or  soft  ointments  locally  applied,  together  with 
such  internal  measures  as  may  be  indicated.  Probably,  the  compound 
tincture  of  Lobelia  and  Capsicum  might  aid  in  causing  sufficient 
relaxation  to  permit  its  reduction;  but  from  the  nausea  and  vomiting 
which  this  might,  probably,  produce,  I  would  prefer  the  following 
plan:  Having  emptied  the  bladder  and  rectum,  place  the  patient 
under  the  relaxing  influence  of  the  tincture  of  Gelsemium  ;  at  the 
same  time,  should  the  uterus  be  external  to  the  vulva,  envelop  it  in 
cloths  wet  with  warm  water,  without  permitting  any  evaporation  to 
take  place,  changing  them  from  time  to  time,  if  necessary.  Relaxation 
of  the  muscular  fibers  of  the  organ  having  followed  this  course,  then 
attempt  the  reduction.  I  have  never  had  an  opportunity  of  trying 
this  method,  but  merely  suggest  it  to  the  profession ;  from  a  knowledge 
of  the  influence  of  the  agents  named,  upon  the  system,  I  believe  it 
will  be  found  successful  in  very  many  instances  of  chronic  inversion. 


544  KING'S  ECLECTIC  OBSTETRICS. 

At  all  events  I  should  try  it,  before  undertaking  any  of  the  severe 
and  painful  methods  recommended  for  removing  the  uterus.  Long 
continuous  pressure  upon  the  inverted  fundus,  by  means  of  elastic 
bags  filled  with  water,  and  then  passed  into  the  vagina,  has  also 
been  advised. 

After  the  replacement  of  a  chronic  inversion,  the  female  should  be 
treated  the  same  as  advised  under  the  acute  form;  and,  in  either  form, 
it  may  be  beneficial  to  protect  the  uterus,  for  a  number  of  weeks  or 
months,  from  the  superincumbent  weight  of  the  intestines,  by  the 
application  of  an  abdominal  supporter  immediately  below  the  um- 
bilicus, whose  force  shall  be  directed  inward  and  upward. 

When  the  inversion  can  not  be  overcome,  palliative  measures  are 
all  that  can  be  recommended,  and  if  the  uterus  falls  out  of  the  vulva, 
it  should  be  placed  beyond  external  danger,  by  returning  it  within 
the  vagina,  and  retaining  it  there  by  a  bandage  and  compress;  at  the 
same  time  using  the  abdominal  supporter  above  referred  to. 

It  has  been  advised  by  several  eminent  writers  to  remove  the  uterus, 
in  irreducible  cases,  by  the  ligature,  e"craseur,  or  the  knife;  and 
instances  are  not  wanting  where  its  extirpation  by  these  means,  or  by 
gangrene  and  sloughing,  the  result  of  its  strangulation  by  the  os  uteri, 
has  resulted  favorably.  Still,  as  long  as  the  female  experiences  no 
great  amount  of  discomfort,  or  any  alarming  symptoms,  I  can  see  no 
necessity  for  the  operation — it  appears  to  me  cruel  and  uncalled  for, 
especially  when  we  bear  in  mind,  that  females  have  labored  under 
this  accident  for  many  years  without  any  very  unpleasant  or  exhaust- 
ing symptoms.  Beside  which,  cases  of  spontaneous  reduction  have 
been  recorded,  in  which  pregnancy  subsequently  occurred ;  although 
th'is  is  by  no  means  desirable. 

However,  should  the  uterus  be  attacked  by  some  malignant  disease, 
while  in  this  displaced  condition,  its  extirpation  may  be  followed  by 
favorable  results.  The  ligature  employed  is  usually  either  silk,  silver- 
wire,  or  whip-cord ;  it  may  be  applied  around  the  uterus  at  its  highest 
part,  and  gradually  tightened  as  the  patient  can  bear  it,  until  the  sep- 
aration has  taken  place.  Should  it  cause  any  violent  symptoms,  it 
must  be  loosened  for  a  time,  until  these  have  been  subdued.  The 
strength  of  the  patient  must  be  kept  up  by  a  non-stimulating,  nutri- 
tious diet. 

When  the  knife  is  employed,  a  ligature  should  be  first  applied  as 
above,  for  the  purpose  of  preventing  hemorrhage,  and  the  excision  be 
made  immediately  below  the  ligature.  In  a  case  where  extirpation  of 


COMPLICATED  LABOR — RUPTURE  OF  THE  UTERUS.      545 

the  inverted  uterus  would  be  desirable,  instead  of  the  preceding  opera- 
tions, I  would  first  endeavor  to  remove  it  by  means  of  Galvanic  Heat, 
which  I  believe  would  eifect  it  without  the  loss  of  much  blood,  or  any 
subsequent  dangerous  inflammation.  This  heat  may  be  applied,  by 
attaching  a  platina  point  to  the  end  of  a  copper  or  iron  wire,  then,  by 
bringing  the  two  poles  of  a  galvanic  battery  to  act  upon  this  point,  a 
heat  will  be  obtained  of  sufficient  intensity  to  destroy  all  animal  tissues 
to  which  it  may  be  applied,  without  any  great  degree  of  suffering.  I 
have  used  this  successfully  in  fistula  in  ano,  and  in  urethral  stricture. 

Occasionally,  instances  of  a  RUPTURE  OF  THE  UTERUS  are 
met  with,  which  generally  prove  fatal.  This  accident  may  occur  during 
pregnancy,  or  at  an  advanced  period  of  life,  but  it  is  only  of  its  exist- 
ence during  parturition  that  I  shall  treat.  It  is  stated  to  occur  about 
once  in  1318  cases  of  labor. 

Rupture  of  the  uterus  occurs  more  frequently  among  multiparse,  and 
especially,  it  is  stated,  with  male  fetuses,  who  are  usually  larger  than 
females ;  it  may  be  owing  to  several  causes,  as,  debility  or  disorganiza- 
tion of  the  uterine  tissue,  effected  by  inflammation  during  pregnancy; 
cases  of  thinning,  softening,  scirrhus,  and  gangrene  of  the  uterine 
walls,  have  been  recorded.  An  abnormal  size  of  the  fetal  head, 
may  be  a  cause ;  as  well  as  obliquity,  or  retroversion  of  the  uterus— 
transverse  presentation  of  the  body,  or  the  head  presenting  obliquely 
at  the  superior  strait ;  the  presence  of  a  polypus ;  an  excess  of  liquor 
amnii ;  and  plurality  of  children,  have  all  been  named  as  causes.  It 
may  occur  from  violence,  as  falls,  blows,  kicks,  etc.,  forcible  attempts 
at  delivery  by  turning  or  otherwise,  and  has  been  known  to  follow  a 
fit  of  anger.  A  cicatrix  in  the  os  and  cervix  uteri  may  tend  to  its 
occurrence.  A  rigid  os  uteri  may  occasion  it,  and  instances  have  been 
observed  where  the  os  has  been  entirely  torn  off;  females  who  have 
deformed  pelves,  or  those  on  whom  the  Cesarean  operation  has  been 
performed  at  a  previous  labor,  are  very  liable  to  it.  Violent  efforts 
of  the  uterus  itself,. and  especially  when  induced  by  the  exhibition  of 
ergot,  or  stimulants,  will  tend  to  lacerate  the  organ. 

Among  these  enumerated  causes,  probably,  those  which  more  fre- 
quently give  rise  to  the  accident,  are  morbid  alterations  in  the  uterine 
tissue ;  violent  contractions  of  the  uterus ;  a  forcible  entrance  through 
the  undilated  os;  and  undue  violence  in  turning,  or  otherwise  assisting 
the  delivery;  though,  it  may  occur  during  the  operation  of  turning, 
from  some  diseased  state  of  the  cervix,  the  operator  being  blameless. 
35 


546  KING'S  ECLECTIC  OBSTETRICS. 

The  rupture  may  happen  at  any  part  of  the  uterus,  though  it  is  most 
frequently  met  with  at  the  cervix,  either  anteriorly,  opposite  the  pubes, 
or  posteriorly,  opposite  the  sacral  promontory,  and  generally  at  the 
point  complained  of  by  the  patient  as  being  excessively  painful.  Its 
direction  is  not  constant — with  some  it  may  be  longitudinal,  and  with 
others  oblique  or  transverse ;  and  it  may  be  accompanied  with  a  lacer- 
ation of  the  vagina. 

Its  occurrence  may  be  sudden,  or  it  may  take  place  gradually;  and 
the  laceration  may  be  complete,  extending  through  the  uterine  texture 
and  its  peritoneal  covering;  or,  partial,  being  confined  only  to  the 
peritoneum,  or  to  the  muscular  texture. 

SYMPTOMS. — Rupture  of  the  uterus  most  frequently  follows  a 
powerful  effort  of  contraction,  during  which '  the  female  suddenly 
screams  that  something  has  ruptured  within  her.  The  pain  accom- 
panying this  sensation  is  very  acute  and  agonizing,  and  is  frequently 
expressed  as  "  a  crampy  pain ;"  and  it  is  the  intensity  of  this  which 
causes  the  shrieks  of  the  patient.  Frequently  the  rupture  is  mani- 
fested to  the  bystanders  by  a  tearing  or  cracking  noise. 

The  pains  soon  become  feeble,  or  cease  Immediately,  according  to 
the  complete  or  incomplete  nature  of  the  rent,  and  a  violent,  constant, 
excruciating  pain,  entirely  different  from  that  caused  by  uterine  con- 
traction, is  most  generally  complained  of,  as  being  confined  to  one 
spot. 

The  pulse  soon  becomes  rapid,  small,  feeble,  and  fluttering ;  the 
countenance  quickly  assumes  a  pallid,  anxious,  and  alarmed  appear- 
ance; the  respiration  becomes  hurried  and  difficult;  the  surface  is  cold 
and  clammy;  violent  retching  ensues,  with  vomiting  of  mucus,  a 
greenish  matter,  or  a  dark-colored  substance  resembling  coffee-grounds ; 
there  is  faintness,  with  an  inability  to  lie,  requiring  the  female  to  be1 
raised  in  the  bed;  external  or  internal  hemorrhage  may  occur,  but  the 
flooding  is  frequently  absent,  there  being  but  a  slight  discharge  of 
blood;  and  sometimes  convulsions  happen. 

Should  the  peritoneal  coat  only  be  rent,  the  labor  may  go  on,  and 
the  child  be  delivered ;  and,  occasionally,  the  last  pains  which  expel 
the  child,  may  at  the  same  time  effect  a  complete  rupture  of  the  uterus. 

DIAGNOSIS. — In  connection  with  the  symptoms  above  named,  an 
examination,  externally,  will  discover  the  uterus  contracted  in  one  or 
the  other  iliac  region,  and  the  child  may  be  plainly  detected,  through 
the  abdominal  parietes,  when  the  rupture  is  complete.  An  examination 
per  vaginam  will  ascertain  that  the  presenting  part  has  receded  so  as 


COMPLICATED    LABOR RUPTURE    OF    THE    UTERUS.  547 

"barely  to  be  felt  by  the  finger,  unless  it  be  impacted,  or,  it  may  have 
passed  entirely  out  of  reach,  the  child  having  escaped  into  the  cavity 
of  the  abdomen.  The  death  of  the  fetus  generally  happens  immedi- 
ately, so  that  if  the  fetal  pulsations  can  be  heard,  it  is  considered 
indicative  of  no  rupture.  A  partial  rent  is  of  more  difficult  diagnosis; 
\ve  must  be  guided  by  the  pain,  and  the  collapsed  condition  of  the 
patient. 

PROGNOSIS. — The  prognosis  is  always  serious,  as  very  few  evei 
recover  from  the  accident.  The  shock  may  destroy  the  patient  imme- 
diately or  in  a  few  hours  after  the  rupture;  if  the  collapse  does  not 
prove  fatal,  she  may  die  subsequently  of  peritonitis,  or,  secondary 
affections  may  finally  destroy  her,  as  lumbar  abscess,  sub-peritoneal 
abscess,  etc.  Even  slight  lacerations  of  the  os  uteri  have  proved  fatal. 
If  the  peritoneal  coat  be  not  ruptured,  there  will  be  danger  of  peri- 
tonitis. Metritis  will  be  apt  to  follow  a  laceration  of  the  muscular 
tissue. 

Although  the  fatality  attending  this  casualty  is  very  great,  still, 
cases  are  recorded  in  which  recovery  has  followed,  and  even  where 
children  have  been  given  birth  to,  subsequently;  so  that  in  no  case  is 
the  practitioner  to  abandon  it  as  irrecoverable — his  duty  is  to  use  every 
effort  to  save  his  patient. 

TREA.TMENT. — In  a  labor  where,  from  the  violence  of  the  pains, 
or  the  presence  of  a  fixed,  crampy  pain,  or  other  well-founded  reason, 
rupture  of  the  uterus  is  apprehended,  the  delivery  should,  if  possible, 
be  hastened — but  not  by  Ergot,  or  stimulants.  It  would  also  be 
advisable  to  moderate  the  pains  by  the  agents  heretofore  named,  as 
Sp.  Trs.  of  Gelsemium,  Aconite,  etc.  The  forceps  should  l>e  en.- 
ploycd  when  safe  and  practicable ;  but  if  the  child  be  dead,  and  any 
resistance  be  offered  to  its  advance  by  the  forceps,  the  perforator  should 
IK-  used.  Counsel  should  always  be  sent  for. 

If  the  rupture  has  occurred,  the  only  chance  for  the  patient  is  in 
immediate  delivery.  If  the  head  be  within  reach,  the  child  may  be 
cautiously  extracted  with  the  forceps;  or,  if  this  can  not  be  effected, 
then  the  perforator  must  be  used,  taking  especial  care,  with  either 
instrument,  not  to  push  up  the  head,  lest  it  slip  through  the  rent  into, 
the  abdominal  cavity.  This  may  be  avoided  by  an  attendant  making 
pressure  over  the  fundus,  and  the  operator  causing  the  perforation  to 
be  gently  made  in  a  direction,  as  much  as  possible,  toward  the  sacrum. 
Should  the  presentation  be  of  the  shoulder,  or  the  face,  or  the  nates, 
bring  down  the  feet,  and  thereby  hasten  the  expulsion,  as  well  as  pro- 


548  KINK'S  ECLECTIC  OBSTETRICS. 

vent  the  child  from  passing  into  the  abdominal  cavity.  The  child 
being  delivered,  follow  the  cord,  and  carefully  remove  the  placenta. 

If  the  child  has  passed  into  the  ventral  cavity,  the  hand  and  arm 
should  at  once  be  oiled  and  insinuated  steadily  along  the  vagina,  into 
the  uterus,  and  through  the  rent  into  the  cavity  of  the  abdomen ;  the 
feet  of  the  child  should  then  be  seized  and  brought  down,  extracting 
it  through  the  ruptured  opening  into  the  uterus  and  delivering  by  the 
natural  passages.  This  accomplished,  reintroduce  the  hand,  if  neces- 
sary, to  remove  the  placenta.  But  in  either  case,  be  especially  careful 
not  to  abstract  any  portion  of  the  intestines  along  with  the  child,  or 
placenta;  and  if  any  part  of  them  has  entered  the  fissure,  remove 
them,  that  they  may  not  be  strangulated  by  the  subsequent  contraction 
of  the  uterus.  Make  no  attempts,  however,  toward  their  proper 
replacement;  when  remaining  within  the  abdomen  any  interference  to 
adjust  them  is  improper. 

But  the  os  uteri  may  not  be  dilated,  or  not  sufficiently  so  for  the 
introduction  of  the  hand,  or,  after  the  child  has  escaped  through  the 
rent,  the  uterus  may  contract — in  either  case — rendering  delivery  by 
the  natural  passages,  impossible ;  what  must  be  done?  It  is  advised 
by  eminent  authority,  that  if  the  female  has  not  suffered  much  from 
the  shock,  and  other  circumstances  are  favorable,  to  explain  to  her 
the  nature  of  the  accident,  and  with  her  consent,  perform  the  Cesarean 
section,  and  remove  the  child  and  placenta  through  the  abdominal 
parietes.  If,  however,  she  be  rapidly  sinking,  or  half  an  hour  has 
elapsed  and  the  fetus  is  dead,  leave  the  case  to  nature.  The  practitioner 
will,  however,  be  guided  by  circumstances,  everything  will  depend 
upon  his  judgment  aided  by  that  of  his  counsel,  and  no  safe  means 
must  be  left  unemployed  which  may  tend  to  preserve  both  mother  and 
child. 

While  the  patient  is  in  a  collapsed'  condition,  various  agents 
may  be  given  to  arouse  the  vital  energy,  and  prevent  it  from  be- 
coming too  far  depressed.  Alcoholic  stimulants,  as  well,  as  Ether, 
Ammonia,  etc.,  should  be  given  freely;  also  apply  stimulants  ex- 
ternally. 

After  the  delivery,  when  all  indications  of  collapse  have  dis- 
appeared, to  diminish  nervous  excitement,  Opium,  Morphia,  com- 
pound powder  of  Ipecacuanha  and  Opium,  Hyoscyamus,  or  other 
anodyne  may  be  given.  The  subsequent  inflammation,  if  excessive, 
must  be  met  by  Sp.  Trs.  of  Aconite,  Gelsemium,  Macrotys,  Pulsa- 
tilla,  Phytolacca,  etc.,  which  should  be  exhibited  in  sufficient  quan- 
tity to  diminish  the  severity  of  the  inflammation,  but  not  to  overcome 


COMPLICATED    LABOR  -  RUPTURE    OF    THE    UTERUS.  549 

it  entirely,  for  a  certain  amount  of  inflammatory  reaction  is  required 
for  a  cure  Severe  inflammatory  reaction  may  induce  (dangerous)  peri- 
tonitis, to  which,  indeed,  the  patient  is  very  liable,  and  which  should 
constantly  be  borne  in  mind.  The  strength  of  the  system  must  be  sup- 
ported. Poultices  or  fomentations  of  Hops  and  Stramonium  leaves,  or 
the  old  time  Spice  Poultice  (Am.  Dispensatory]  over  the  abdomen,  will 
also  be  found  of  much  benefit  when  symptoms  of  peritonitis  are  present. 

The  VAGINA  MAY  BE  LACERATED,  in  connection  with  the 
uterus,  or  independent  of  it;  it  is  more  unfrequent  than  uterine  rup- 
ture. The  symptoms  resemble  those  of  rupture  of  the  uterus,  and  are 
nearly  as  dangerous.  If  the  laceration  be  trifling,  it  is  better  to  leave 
the  case  to  nature,  watching  it  carefully,  however,  and  bestowing  some 
care  to  the  support  of  the  perineum,  as  the  head  passes  over  it.  If 
there  be  danger  of  an  extension  of  the  laceration,  hasten  the  delivery, 
by  forceps  if  possible.  The  after-treatment  will  be  similar  to  that  in 
the  preceding  accident. 

RUPTURE  OF  THE  BLADDER,  is  a  more  fatal  occurrence 
than  that  of  the  uterus,  it  is  extremely  rare,  and  may  arise  from  neglect 
or  inattention  of  the  practitioner,,  or  the  improper  use  of  instruments. 
Its  symptoms  are  somewhat  similar  to  those  of  rupture  of  the  uterus, 
as  a  violent  and  severe  pain  in  the 'region  of  the  bladder;  a  scream 
from  the  patient ;  a  sensation  of  something  having  given  away  inter- 
nally ;  rapid  depression  of  the  vital  powers ;  tumefaction  and  tender- 
ness of  the  abdomen  ;  but  no  recession  of  the  presenting  part,  or 
distinguishing  the  child  in  the  abdomen.  The  contractions  of  the 
womb  continue,  but  grow  weaker  as  the  system  sinks. 

This  accident  may  be  prevented  by  proper  care  on  the  part  of  the 
practitioner,  who  will  ascertain  that  the  organ  is  emptied  during  labor, 
or  if  it  be  full,  and  the  patient  can  not  void  the  urine,  he  must  intro- 
duce a  flexible  catheter  and  thus  eifect  the  evacuation.  When  the 
rupture  occurs,  the  child  should  be  saved,  if  possible,  there  being  but 
little  hope  for  the  mother.  The  delivery  should  be  hastened  by  turn- 
ing, or  the  forceps,  if  the  child  be  alive ;  and  if  this  can  not  be 
effected,  the  Cesarean  operation  has  been  advised.  The  death  of  the 
child  usually  ensues  in  consequence  of  the  prostration  of  the  mother. 

SYNCOPE,  occasionally  attacks  females  either  -during  labor,  or 
subsequently  thereto,  and  may  occur  independently  of  hemorrhage,  or 
rupture  of  the  uterus,  vagina,  or  bladder. 


550  KING'S  ECLECTIC  OBS-TETKH  >. 

Those  of  a  nervous,  hysterical,  delicate  habit,  are  more  liable  to  it,, 
though  it  is  also  met  with  among  those  who  have  prostrated  the  ener- 
gies of  the  system  by  intemperance,  or  unhealthy  diet  with  impure  air. 
It  may  also  be  occasioned  by  some  organic  disease,  as  of  the  heart 
and  lungs,  or  from  the  rupture  of  an  aneurism,  or  abscess,  in  which 
instances  it  may  prove  fatal.  It  also  undoubtedly  occurs  from  the 
sudden  removal  of  the  pressure  of  the  contents  of  the  gravid  uterus 
upon  the  abdominal  viscera  and  large  vessels  of  the  body.  Females 
of  a  despondent  or  gloomy  state  of  mind,  or  who  are  apprehensive 
concerning  the  termination  of  their  labor,  are  also  subject  to  it. 

A  prudent  exhibition  of  Wine,  Ether,  Ammonia,  or  other  stimu- 
lants, to  invigorate  the  energies  of  the  system,  with  moderate  warmth, 
fresh  air,  depression  of  the  head  and  shoulders,  a  sprinkling  of 
Ammonia  or  Camphor  upon  the  face  and  neck,  and  frictions  to  the 
extremities,  will  commonly  be  sufficient  to  restore  the  patient.  Sul- 
phate of  Quinia,  or,  Fluid  Extract  of  Erythroxylon  Coca,  will  also  be 
useful.  Of  course,  when  the  symptom  happens  from  organic  diffi- 
culty, the  probability  of  rallying  the  female  will  depend  upon  the 
character  of  the  disease.  When  it  occurs  after  the  delivery,  in  addition 
to  the  above  means,  apply  friction  to  the  abdomen,  together  with  a 
broad  bandage  firmly  and  properly  applied. 

Sometimes  an  extravasation  of  blood  into  one  or  both  of  the  labia 
pudendi,  suddenly  o.ccurs  during  labor,  or  shortly  after  the  birth  of 
the  child,  which  is  termed  THROMBUS.  It  is  the  result  of  a  rupture 
of  varicose  veins  of  the  vagina,  or  of  some  of  the  large  blood-vessels. 

The  affected  labia  present  the  appearance  of  a  livid  or  black  tumor, 
of  -greater  or  less  size,  frequently  as  large  as  the  head  of  a  child,  being 
accompanied  with  intense  pain. 

Dr.  Dewees  states,  that  if  the  inner  surface  of  the  attacked  labiuin 
does  not  burst  in  the  first  instance,  the  tumor  is  certain  to  yield  iu 
a  short  time  from  gangrene.  A  large  surface  of  coagulated  blood 
becomes  exposed  when  the  part  sloughs,  which  rapidly  decomposes 
and  becomes  fetid.  If  the  parts  do  not  rupture,  the  patient  suffers 
most  excruciating  pain :  active  fever  takes  place  with  delirium,  and 
her  life  becomes  seriously  endangered.  A  retention  of  urine  increases 
her  sufferings,  and  relief  can  only  be  obtained  by  making  a  free 
incision  on  the  mucous  face  of  the  labium,  to  allow  the  extravasated 
blood  to  escape,  and  which  should  be  done  before  the  process  of  ulcer- 
ation  has  commenced,  or  the  chance  of  bursting.  Then  press  the- 


COMPLICATED  LABOR — THROMBUS.  551 

enlarged  labium  to  one  side,  and  evacuate  the  bladder  by  means  of 
the  catheter. 

Thrombus  is  most  commonly  present  in  cases  of  protracted  labor 
caused  by  pelvic  deformity,  and  generally  proves  fatal,  especially  if  not 
attended  to  at  an  early  period.  Sometimes  its  progress  is  very  rapid, 
the  blood  effused  being  so  great  in  quantity  as  to  cause  syncope ;  or 
the  mucous  membrane  may  rupture,  followed  by  a  cessation  of  pain, 
and  a  hemorrhage,  which  may  be  so  excessive  as  to  rapidly  destroy  the 
patient. 

These  tumors  must  not  be  confounded  with  inversion  of  the  uterusr 
or  of  the  vagina,  or  with  cystocele,  vaginal  hernia,  etc. 

TREATMENT.— If  this  difficulty  happens  during  labor,  and  the 
tumor  interferes  with  the  passage  of  the  head,  it  should  be,  freely 
incised  on  the  mucous  surface  (the  extent  of  the  incision  being  in  pro- 
portion to  the  size  of  the  swelling),  and  the  fluid  allowed  to  escape. 
Should  it  be,  however,  excessive  in  quantity,  too  great  a  discharge 
must  be  checked  by  applications  of  cold,  ice,  and  compression,  which 
must  be  continued  until  the  engagement  of  the  head,  by  pressing  upon 
the  ruptured  vessels,  prevents  any  further  flow. 

If  the  thrombus  occurs  during  pregnancy,  or  after  delivery,  with 
only  a  small  tumor,  but  little  discoloration  of  the  skin,  and  no  per- 
ceptible increase  of  the  effusion,  and  no  fluctuation,  attempts  should 
be  made  to  resolve  it,  by  the  application  to  the  parts,  of  cataplasms  of 
Elm  and  Arnica  flowers,  or  Elm  and  flowers  of  St.  Johnswort,  aided 
by  warm  fomentations  to  the  hands,  feet,  and  legs.  And  the  same 
course  may  be  pursued  after  delivery,  when  the  tumor  ceases  to  enlarge, 
carefully  watching,  however,  and  opening  it,  upon  the  first  appearance 
of  inflammatory  symptoms. 

If  the  tumor  continues  to  increase,  with  debility  and  sinking  of  the 
system,  incise  it,  as  before  named,  evacuate  at  least  the  greater  part 
of  the  clots  present,  by  the  fingers,  and  then  make  firm  and  permanent 
compression  upon  the  whole  tumor,  together  with  applications  of  ice 
or  styptics,  if  the  effusion  does  not  readily  cease.  As  profuse  hemor- 
rhage, or  severe  inflammation  may  subsequently  supervene,  the  practi- 
tioner should  be  fully  prepared  to  encounter  them. 

Always  sustain  the  strength  of  the  patient  by  appropriate  stimuli, 
nourishing  diet,  etc.;  and  keep  down  febrile  symptoms  by  the  proper 
administration  of  the  indicated  sedatives,  together  with  such  other 
agents  as  are  specifically  indicated  or  peculiarly  adapted  to  the  con- 
ditions present.  Keep  the  bowels  ngular,  enjoin  quiet,  the  recum- 


KING'S    ECLECTIC    OBSTETRICS. 

bent  position,  and  cleanliness  of  the  parts,  and  do  not  suffer  the 
bladder  to  become  overdistended  with  urine.  The  Sp.  Trs.  of  Gel- 
.-einiuni,  with  a  small  proportion  of  Aconite  added,  or  the  appli- 
cation of  Tr.  of  Veratrum  Vir.,  will  prevent  any  subsequent  attack 
of  erysipelas,  or  peritoneal  inflammation,  in  many  instances. 


CHAPTER  XLI. 

COMPLICATED    LABOR — PUERPERAL   CONVULSIONS — ECLAMPSIA- 
HYSTERICAL   CONVULSIONS — APOPLEXY — EPILEPSY. 

ONE  of  the  most  dangerous  and  frightful  maladies,  with  the  excep- 
tion of  inversion  and  rupture  of  the  uterus,  with  which  the  puerperal 
female  may  be  attacked,  is  CONVULSIONS.  (Eclampsia  puerperalis). 
It  usually  occurs  during  labor,  though  occasionally  met  with  for  some 
time  previously,  but  seldom  before  the  sixth  month  of  pregnancy ;  and 
it  frequently  manifests  itself  after  delivery,  when  it  is  generally,  but 
not  always,  of  a  more  favorable  character. 

According  to  statistics,  it  is  fortunately  a  rare  disorder,  having 
occurred  in  172  cases  of  labor,  out  of  103,537 ;  or  about  1  in  602. 
Primipara?  are  more  subject  to  it ;  instances,  however,  have  presented 
of  multipart  who  were  attacked  by  it  in  their  tenth  or  twelfth  labors. 
The  fatality  of  the  mother,  heretofore,  has  been  about  one  in  every 
four;  most  commonly  the  children  are  still-born.  Females  with  short, 
thick  necks,  of  low  stature,  and  square  form,  and  of  a  sanguine  tem- 
perament, are  considered  to  be  more  subject  to  it — yet  none  are 
entirely  exempt  from  it.  It  frequently  attacks  those  who,  in  early 
life,  suffered  from  epilepsy,  hysteria,  or  who  have  received  injuries  of 
the  head. 

Beside  the  true  puerperal  convulsions,  there  are  three  other  varieties 
which  may  attack  the  parturient  female,,  viz.:  the  hysteric,  the  apo- 
plectic, and  the  epileptic,  each  of  which  will  require  a  separate  notice. 

HYSTERIC  CONVULSIONS,  with  their  treatment,  have  been  referred 
to  under  the  Diseases  of  Pregnancy.  A  few  inhalations  of  Chloro- 
form will  likeVise  frequently  remove  them.  It  may  be  proper, 
however,  to  name  the  distinguishing  marks  between  these  and  the 
true  puerperal  convulsions. 


COMPLICATED  LABOR — PUERPERAL    CONVULSIONS. 


553 


IN   HYSTERIC    CONVULSIONS. 

1.  Consciousness  may,  or  may  not  be  en- 
tirely lost;   generally  the  insensibility   is 
incomplete.     A   dash  of  cold  water  upon 
the   face  and  chest  will  often    restore  the 
patient,  and  will  at  least  make  her  start. 
If  labor  pains  are  on,  they  will  cause  her 
to  wince,  and  an  attempt  to  make  an  ex- 
amination will  be  opposed. 

2.  The  spasmodic  action  is  moderate,  the 
body  being  but  slightly  contorted. 

3.  No    frothing   at    the  mouth,  and   no 
biting  the  tongue. 

4.  The  breathing  is  not  stertorous   nor 
hissing. 

5.  The  convulsive  attacks   are  not  fre- 
quent, the  patient  recovering  shortly  after 
each. 

6.  There  may  be  sobbing,  sighing,  weep- 
ing, and  screaming. 


IN   PUERPERAL  CONVULSIONS. 
1.  Consciousness  is  completely  lost. 


2.  The  spasmodic  action  is  violent,  with 
powerful    and    irregular  agitation   of   the 
muscular  system. 

3.  Frothing  at  the  mouth,  with  biting  of 
the  tongue. 

4.  The  breathing  is  rapid    and  violent, 
with  a  loud,  peculiar,  hissing  sound. 

5.  The  paroxysms  are  frequent,  with  to- 
tal insensibility,  or  incomplete  conscious- 
ness during  the  intervals. 

6.  Sobbing,  sighing,  weeping  and  scream- 
ing, are  never  present. 


APOPLECTIC  CONVULSIONS,  when  present,  almost  always,  with  but  a 
few  exceptions,  occur  toward  the  termination  of  labor;  and  are 
caused  by  the  pressure  exerted  upon  the  cerebral  vessels  during  the 
contractions  of  the  uterus.  They  are  rarely  met  with,  and  most 
usually  prove  fatal. 

Sometimes  no  premonitory  symptoms  will  be  present;  at  others, 
there  will  be  pain,  and  throbbing,  with  other  disturbance  of  the  head, 
for  several  days  previously.  During  labor,  there  will  usually  be  more 
or  less  headache,  and  in  the  expulsive  stage,  the  countenance  will  be 
flushed,  with  a  fullness  of  the  vessels  of  the  eyes.  There  will  be 
some  agitation  of  the  limbs  and  body,  with  but  little  spasmodic  action; 
seldom  any  distortion  of  the  face,  no  frothing  at  the  mouth  ;  the 
pulse  is  full  and  slow,  and  the  pupils  fixed,  and  either  contracted  or 
dilated,  and  insensible  to  light.  The  breathing  is  stertorous ;  the 
muscles  soon  become  flaccid  and  powerless  :  the  patient  lies  in  a  coma- 
tose condition,  and  very  rarely  has  a  second  paroxysm. 

The  following  are  the  marks  of  discrimination  between  these  and 
the  true  puerperal  convulsions  : 

IN   APOPLECTIC   CONVULSIONS.  IN  PUERPERAL   CONVULSIONS. 

1.  The   convulsive    movements    at    the         1.  The  convulsions  are  violent  and  are 

commencement  are  slight,  and  are  not  re-  repeated,   with    intervals    of   quiet,    and 

peated,  the  unconsciousness  being  persist-  often  a  more   or  less  complete   return  to 

ent.     Sense  and  sensibility  are  completely  consciousness, 
lost. 


554  KING'S  ECLECTIC  OBSTETRICS. 

2.  The  breathing  is  stertorous.  2.  The  breathing  is  violent,  with  a  lo»dv. 

hissing  sound. 

3.  The  muscles  become  flaccid  and  pow-         3.  The  muscles  preserve  their  tone,  even 
erless.  during  the  intervals. 

PATHOLOGY. — The  brain  will  occasionally  be  found  much  con- 
gested, without  effusion  ;  sometimes,  the  pressure  of  a  great  effusion 
of  serum  causes  the  attack ;  more  commonly,  blood  is  poured  out  into 
the  substance  of  the  brain,  or  at  its  base.  It  is  almost  impossible  to- 
distinguish  the  congestive  form  from  that  caused  by  effusion  ;  the  prin- 
cipal difference  exists  in  the  intensity  of  the  symptoms.  (Churchill.) 

TREATMENT. — Prompt  and  energetic  measures  can  alone  be  of 
service  in  these  cases.  In  cases  that  prove  fatal,  external  stimulating 
measures  will  not  be  responded  to  by  any  reflex  action.  Cold  water, 
or  ice  should  be  applied  to  the  head  and  neck,  a  brisk  purgative  ene- 
ma, to  empty  the  lower  bowels,  should  be  given  as  soon  as  it  can  be 
prepared,  and  warmth  and  friction  should  be  applied  to  the  inferior 
extremities  and  lower  half  of  the  trunk.  In  the  application  of  the 
water,  the  head  should  be  withdrawn  carefully  from  the  bed,  and  held 
over  some  large  vessel  to  receive  the  fluid  after  it  has  been  poured  on. 
If  no  effect  is  produced  by  these  measures,  active  counter-irritation  to 
the  occiput  and  neck  may  prove  valuable.  If  the  attack  occurs  during 
labor,  the  delivery  should  be  hastened  as  speedily  as  may  be  done  with 
propriety,  but  always  without  force  or  rudeness. 

The  above  measures  should  be  persisted  in  for  some  time.  If  a 
return  to  consciousness  follows,  administer  a  purgative  as  soon  as  the 
patient  can  swallow,  apply  warmth  and  counter-irritation  to  the  ex- 
tremities, and  keep  the  head  cool.  Always  be  certain  that  the  bladder 
is  evacuated,  and  does  not  become  distended. 

EPILEPTIC  CONVULSIONS  do  not  vary  in  their  symptoms  and  treat- 
ment from  those  of  ordinary  epilepsy ;  they  very  rarely  occur  with 
parturient  females,  unless  they  have  had  previous  attacks,  and  are  sub- 
jects of  the  disease.  But  epileptic  females  are  not  more  liable  to 
puerperal  convulsions  than  others.  The  symptoms  of  epilepsy  so  much 
resemble  those  of  eclampsia,  that  it  would  be  impossible  to  distinguish 
between  them  in  the  parturient  female,  unless  we  were  apprised  of  the 
fact  that  she  had  previously  been  subject  to  epileptic  attacks.  And 
even  then,  our  diagnosis  might  be  incorrect,  for  the  reason  that  an 
attack  of  epilepsy,  occurring  at  this  time,  might  be  converted  into  a 
true  eclampsia.  As  epilepsy  may,  however,  when  manifested  during 


COMPLICATED    LABOR— PUERPERAL    CONVULSIONS.  555 

labor,  be  mistaken  for   the   true   puerperal   convulsions,  it  may  be 
proper  to  narie  some  of  the  marks  of  discrimination  between  them 

IN   EPILEPTIC   CONVULSIONS.  IN   PUERPERAL   CONVULSIONS. 

1.  The  aura  epileptica  is  observed.  1.  The  aura  epileptica  is  never  observed. 

2.  There  is  usually  but  one  paroxysm ;  2.  There  are  almost  always  several  par- 
or  where   there  are   several,  they  do  not  oxysms,  rapidly  following  each  other, 
succeed  each  other  rapidly. 

3.  The   patient  has  generally  had   pre-.  3.  The  patient  has  never  been  attacked 
vious  attacks.  with  epilepsy  before. 

TRUE  PUERPERAL  CONVULSIONS  appear  to  partake  both  of 
the  nature  of  epilepsy  and  apoplexy,  and  are  considered  by  many 
eminent  writers  as  veritable  apoplexy  with  violent  spasmodic  paroxysms 
superadded,  the  latter  being  occasioned  by  the  great  degree  of  nervous 
excitability  to  which  all  pregnant  and  parturient  females  are  liable. 

The  causes  of  puerperal  convulsions  are  not  well  understood;  they 
appear  to  be  multiform.  Plethora,  compression  of  the  aorta,  long- 
continued  mental  excitement,  highly  electrical  conditions  of  the 
atmosphere,  persistent  damp,  foggy  weather,  profuse  hemorrhage,  and 
previous  diseases  or  injuries  of  the  head,  have  been  variously  named 
as  predisposing  causes.  Females,  not  married,  who  do  not  enjoy  the 
pleasures  of  society,  and  particularly  who  are  given  to  the  use  of 
liquors,  are  especially  liable  to  them.  It  has  also  been-  supposed,  that 
blood  poisoning,  from  a  retention  of  urea,  occurring,  either  from 
the  presence  of  Bright's  disease,  or  from  pressure  upon  the  emulgent 
veins  by  temporary  congestion  upon  the  kidney,  has  occasioned  the 
paroxysms*  According  to  Dr.  Lever,  albuminous  urine  and  puerperal 
convulsions  are  frequently  met  with  together,  very  few  cases  of  the 
latter  occurring  which  do  not  give  evidences  of  the  presence  of 
albumen.  Athill  states  that  "it  is  proved  beyond  all  manner  of 
doubt,  that  in  the  immense  majority  of  cases,  in  at  least  90  per  cent., 
albuminous  urine  and  puerperal  convulsions  are  synonymous  terms." 
M.  Bouchut  holds  to  the  opinion  that  the  cause  of  eclampsia  is 
encephalo-pathic  albuminaria  occasioned  by  serous  effusion  of  the 
meninges  of  the  brain,  or,  by  uremic  or  ammoniemic  poisoning  through 
secretory  insufficience  of  the  kidneys.  There  is  no  doubt  but  there 
are  cases  in  which  the  convulsions  are  wholly  post  partum,  the  exciting 
cause  being  a  septicsemic  contamination  of  the  blood. 

Twins,  excess  of  the  amniotic  fluid,  death  of  the  child,  distension 
of  the  bladder,  irritation  of  some  part  of  the  alimentary  tube,  indi- 
gestible food,  severe  labor-pains,  rigidity  of  the  os  uteri,  irritation  of 


556  KING'S  ECLECTIC  OBSTETRICS. 

the  uterine  nerves  by  the  introduction  of  the  hand,  terror,  or  violent 
mental  impressions,  etc.,  have  all  been  viewed  as  exciting  causes. 
Most  probably,  however,  the  nervous  system  of  some  organ,  as  the 
uterus,  stomach,  bladder,  etc.,  transmits  the  irritation,  which  has  been 
occasioned  by  some  derangement  of  its  functions,  to  the  spinal  system 
and  the  brain. 

According  to  Churchill,  Dr.  Tyler  Smith,  "  has  proved  that  convul- 
sions are  not  excited  by  irritation  of  the  cerebrum  alone,  but  by  the 
primary  or  secondary  effects  produced  upon  the  spinal  marrow,  medulla 
oblongata,  or  tubercula  quadrigemina.  And  therefore  that  the  causes 
giving  rise  to  convulsions  may  be  either,  1,  Centric,  such  as  pressure  on 
the  medulla  oblongata  from  congestion,  coagula,  or  serous  effusion 
within  the  cranium ;  loss  of  blood,  morbid  elements  in  the  blood ; 
emotion.  -Or,  2,  Eccentric,  acting  on  the  extremities  of  the  excitor 
nerves,  as  irritation  of  the  incident  spinal  nerves  of  the  uterus 
and  uterine  passages;  irritation  of  the'  excitor  nerves  within  the 
cranium;  irritation  of  the  incidental  spinal  nerves  of  the  rectum; 
irritation  of  the  ovarian  nerves;  irritation  of  the  gastric  and  intestinal 
branches  of  the  pneumo-gastric  nerve;  irritation  of  the  incidental 
spinal  nerves  of  the  bladder;  and  as  probable  causes,  irritation  of  the 
cutaneous  nerves,  of  the  nerves  of  the  mammae,  and  of  the  hepatic 
and  renal  branches  of  the  pneumo-gastric.  More  than  one  of  these 
causes  may,  of  course,  act  at  the  same  time." 

Rosenstein,  of  Groningen,  has  made  some  very  interesting  and 
useful  researches  as  to  the  relation  between  carbonate  of  ammonia  and 
uremia;  he  has  ascertained  that  the  first  only  excites  epileptiform 
phenomena,  and  that  narcotics  are  of  no  use  whatever.  In  uremic 
poisoning,  various  symptoms  may  be  produced,  convulsions,  delirium, 
coma.  But  should  the  uremia  determine  epileptiform  attacks,  and 
carbonate  of  ammonia  be  found  in  the  blood,  we  must  not  accuse  this 
last,  because  it  is  not  always  found  at  first  in  such  cases,  and  because 
the  quantity  found  in  the  blood  is  not  in  relation  with  the  intensity 
of  the  epileptiform  phenomena.  Again,  the  symptoms  occurring  in 
affections  of  the  bladder  or  prostate,  termed  "ammoniemia,"  are  in  no 
way  associated  with  poisoning  by  carbonate  of  ammonia,  the  epilepti- 
form symptoms  occasioned  by  the  latter  being  wholly  wanting  in  the 
former.  Arch.  f.  Path.  Anat.,  V.  Ivi :  3. 

Although  all  females  are  liable  to  attacks  of  this  disease,  yet  those 
who  labor  under  any  of  the  following  conditions,  are  supposed  to  be 
more  disposed  to  it,  and  should,  therefore,  receive  the  earliest  attention 
of  the  medical  man,  in  order  to  prevent  its  attack  :  corpulent  female?, 


COMPLICATED     LABOR — PUERPERAL    CONVULSION'S.  -OO< 

those  having  short  necks;  those  having  firm,  solid,  and  unyielding 
tissues,  or  who  possess  great  muscular  strength;  those  whose  feet  and 
hands  swell,  and  who  experience  a  numbness  in  the  hands,  or  in  the 
limbs,  with  swelling  of  the  face,  on  awaking  every  morning;  those 
who  feel  excessively  weak,  or  who  labor  under  partial  or  complete  loss 
of  sensation  in  one  side  of  the  face  or  limbs ;  those  who  are  subject  to 
headache,  dizziness,  muscse  volitantes,  dimness  of  sight,  double  vision, 
seeing  only  one-half  of  an  object,  or  flashes  of  light  within  the  eyes; 
those  who  experience  loud  noises  in  the  ears,  especially  when  occurring 
suddenly,  or  who  feel  as  if  the  head  had  received  a  violent  blow. 
Anaemic  females,  and  those  who  constantly  complain  of  headache 
during  the  last  month  or  two  of  gestation,  should  receive  especial 
attention. 

The  proper  course  by  which  to  prevent  an  attack  in  such  females, 
no  albumen  being  detected  in  the  urine,  is  to  keep  the  bowels  and 
kidneys  regular  by  laxatives  and  mild  diuretics;  attend  to  the  surface 
by  occasional  bathings,  with  frictions  and  the  use  of  a  proper  amount 
of  clothing;  regulate  the  diet,  that  it  be  nourishing,  but  not  gross  nor 
too  stimulating,  and  agrees  with  the  stomach,  readily  undergoing 
digestion.  '  Exercise  moderately  but  regularly  in  the  open  air,  and 
have  all  sources  of  mental  anxiety  or  agitation  removed.  In  addition 
to  these  measures,  strengthen  the  uterine  nervous  system  by  the  exhi- 
bition of  the  Parturient  Balm,  Macro  tys,  Pulsatilla,  Gelsemium, 
Lobelia,  either  singly  or  in  such  combinations  as  may  appear  the 
best  adapted  to  each  particular  patient.  The  preparation  first  named 
will  be  found  applicable  to  the  greater  number  of  cases.  Small 
doses  of  some  chalybeate  preparation  should  be  given,  in  conjunction, 
to  anaemic  patients.  If  there  are  serious  infiltrations,  diuretics  may 
be  given,  as,  the  officinal  infusion  of  Digitalis,  together  with  saline 
draughts,  as  Seidlitz  powders,  Acetate  of  Potassa,  etc. 

In  all  cases  where  the  accoucheur  is,  for  several  weeks  previously, 
aware  that  he  will  be  the  attendant  of  a  woman  during  labor,  he 
should  from  time  to  time  examine  her  urine,  to  determine  whether 
albumen  be  present,  and  urea  be  diminished  in  amount,  or  be  wholly 
absent;  and  these  examinations  are  more  especially  demanded  in 
primiparous  women,  those  with  short  necks,  where  there  is  a  con- 
dition of  fullness  or  plethora,  oedema,  and  where  the  woman  com- 
plains of  headache  or  giddiness.  If,  in  the  last  month  or  two  of 
pregnancy,  there  is  headache,  redema,  impaired  vision  or  hearing, 
vomiting,  pain  in  the  epigastrium,  or  nervous  symptoms,  the  albu- 
minous urine  being  scanty,  turbid,  high-colored,  containing  granular 


558  KING'S  ECLECTIC  OBSTETRICS. 

or  hyaline  casts,  but  no  blood  or  epithelium,  the  albuminaria  is  due  to 
compression  of  the  emulgeut  renal  vessels  by  the  enlarged  uterus;  and 
the  urine  will  tend  to  resume  its  normal  character  after  parturition. 
But,  if  the  scanty  and  albuminous  urine  exists  at  an  early  period  of 
pregnancy,  before  the  size  of  the  uterus  can  exert  any  pressure,  and 
contains  blood  and  epithelium,  there  is,  undoubtedly,  acute  desquam- 
ative  nephritis. — Johnson. 

When  albumen  has  been  discovered  in  the  urine  of  a  pregnant 
woman,  she  should  at  once  be  placed  under  treatment.  Cathartics, 
such  as  do  not  affect  the  uterus,  should  be  employed,  as,  Cream  of 
Tartar,  Roohelle  Salts,  etc.,  which,  without  depressing  any,  should  be 
kept  up  regularly  until  full  term.  The  skin  should  be  kept  in  a  stim- 
ulated condition  by  hot  air  baths,  or  applications  of  warm  water,  fol- 
lowed by  .drying  with  a  coarse  towel,  using  enough  friction  to  produce 
a  glow  upon  the  surface;  dry  cupping  and  fomentations  over  the 
region  of  the  kidneys  are  also  required.  These  measures  tend  to 
relieve  the  kidneys,  as  well  as  to  aid  the  system  in  its  endeavor  to  re- 
move the  poison  in  the  blood.  Should  any  nervous  irritability  be 
present,  such  agents  are  indicated  as  Pulsatilla,  Belladonna,  Bromide 
of  Potassium,  Digitalis,  etc.  Where  there  is  a  swollen  condition  of 
the  extremities,  or  a  puffiness  of  the  eyelids,  Apocynum  Can.  should 
be  administered.  The  diet  should  be  chiefly  vegetable  and  farina- 
ceous, using  fruits,  berries,  etc.,  when  not  contraindicated,  and  as 
little  meats  as  possible.  There  will,  in  some  cases,  be  a  clear  indica- 
tion for  acids,  and  by  the  judicious  administration  of  Tartaric  Acid, 
or  Lemon  juice,  it  is  claimed,  the  carbonate  of  ammonia  already 
formed  in  such  conditions  may  be  neutralized.  By  these  means  the 
woman  may  be  entirely  relieved  and  prevented  from  having  a  con- 
vulsive attack  at  full  term. 

In  the  very  worst  forms  of  uremic  poisoning,  in  which  the  urine  is 
rendered  almost  solid  by  the  excessive  amount  of  albumen  present,  it 
is  atfvised  to  perform  premature  delivery  at  the  seventh  or  eighth 
month,  in  order  to  save  both  the  child  and  the  mother. 

SYMPTOMS. — The  most  violent  puerperal  convulsions  may  take 
place  without  any  premonitory  symptoms;  but  in  the  majority  of  cases 
they  will  be  met  with.  For  several  days,  or  even  weeks,  previously, 
or  perhaps  for  only  an  hour  or  two,  the  patient  will  complain  of  more 
or  less  severe  headache;  giddiness;  dazzling  of  the  eyes;  weight  and 
constriction  across  the  forehead;  beating  of  the  temporal  arteries; 
disturbance  of  the  sight  and  hearing,  or,  perhaps,  a  sudden  loss  of 


COMPLICATED    LABOR PUERPERAL    CONVULSIONS.  559 

sight;  double  vision;  ringing  in  the  ears;  rigors;  flushed  counte- 
nance; stammering,  or  iucoherency  of  speech;  confused  thought  or 
memory,  slight  delirium,  and  other  indications  of  cerebral  disturb- 
ance. Occasionally,  pains  will  be  felt  in  the  region  of  the  stomach. 
One  or  more  of  these  symptoms  are  premonitory  warnings  of  an 
attack,  and  when  they  exist  demand  prompt  attention  from  the  ac- 
coucheur, who  must  at  once  endeavor  to  prevent  the  paroxysms  by 
appropriate  measures,  as  heretofore  explained. 

No  relief  being  had,  the  symptoms  become  aggravated  until  the 
attack  occurs.  The  face  now  becomes  more  flushed  and  swollen,  the 
eyes  fixed,  and  the  pupils  dilated  [cerebral  anccmia,  as  the  rule] ; 
though  occasionally  cases  will  be  met  with  in  which  the  pupils  con- 
tract closely  [cerebral  congestion,  as  the  rule].  The  patient  rapidly 
becomes  unconscious.  The  voluntary  muscles  of  the  system  become 
violently  and  irregulary  convulsed.  The  head  is  rotated  by  jerks 
from  right  to  left,  or  backward,  the  back  of  the  neck  and  spinal 
column  also  tend  backward  (opisthotonos) ,  and  the  limbs  are  thrown 
with  spasmodic  violence  in  every  direction,  requiring  powerful  efforts 
to  keep  the  female  in  bed.  The  muscles  of  the  face  are  commonly 
affected  first;  the  eyes  roll  rapidly  about,  being  frequently  thrown  up- 
ward and  inward  to  the  root  of  the  nose,  and  irregular  convulsive 
twitchings  may  be  observed  about  the  mouth  and  eyelids.  The  lower 
jaw  becomes  firmly  and  spasmodically  closed  against  the  upper,  or  it 
may  be  drawn  to  one  side.  The  tongue  is  involuntarily  protruded, 
and  is  generally  of  a  livid  color,  and  if  some  care  be  not  taken,  the 
spasmodic  closure  of  the  jaws  will  severely  wound  it,  so  that  the  frothy 
saliva  which  is  blown  from  the  mouth,  sometimes  to  a  considerable 
distance,  will  be  tinged  with  more  or  less  blood;  this  may  be  fre- 
quently prevented  by  placing  a  cork  between  the  teeth  as  soon  as  they 
become  separated.  The  breathing  is  rapid,  irregular,  and  violent, 
and  is  accompanied  with  a  loud,  peculiar  hissing  sound,  owing  to  the 
presence  of  froth  and  the  compression  of  the  lips  and  teeth.  The 
pulse  varies,  but  is  generally  quick,  full,  and  hard,  at  the  commence- 
ment, but  finally  becomes  sjlow  and  hardly  perceptible.  The  face  is 
distorted  by  the  spasmodic  contractions,  and  becomes  turgid  and  livid, 
and  in  which  color  the  hands  and  feet,  as  well  as  the  body,  partic- 
ipate. Frequently  the  contents  of  the  bladder  and  rectum  are  invol- 
untarily evacuated. 

Occasionally,  the  muscles  of  one  side  of  the  face  and  body  are  only 
convulsed,  but,  as  the  spasms  cease,  those  of  the  opposite  side  become 
affected. 


560  KING'S   ECLECTIC   OBSTETRICS. 

After  a  certain  length  of  time,  varying  from  a  few  minutes  to  half 
art  hour,  the  violence  of  the  convulsive  motions  diminish  and  grad- 
ually cease  altogether;  the  features  begin  to  appear  more  natural,  the 
pulse  is  still  quick  but  more  readily  discernible,  restoration  of  the 
circulation  takes  place,  and  the  breathing  becomes  more  regular. 
Consciousness  slowly  returns  in  a  greater  or  less  degree;  the  female, 
wakening,  apparently,  as  if  from  a  sleep,  may  be  aware  that  something 
uncommon  has  occurred,  or,  as  is  more  generally  the  case,  she  may 
have  no  recollection  whatever,  her  mind  being  more  or  less  confused. 
Pain  in  the  head  is  nearly  always  complained  of.  After  an  interval 
of  quiet,  varying  from  fifteen  minutes  to  two  or  three  hours,  the 
paroxysms  return,  when  the  same  phenomena  take  place  as  before, 
followed  by  another  interval;  and  thus  the  paroxysms  and  intermis- 
sions follow  each  other,  until  they  cease  entirely.  I  met  with  one 
female,  in  nay  early  practice,  who  had  sixteen  paroxysms  in  as  many 
hours.  Very  frequently,  in  these  convulsions,  the  consciousness 
returns  very  slowly,  and  immediately  upon  its  first  manifestation  a 
paroxysm. comes  on. 

Consciousness  does  not,  however,  return  in  all  cases;  not  unfre- 
quently  the  patient,  during  the  intervals,  remains  motionless  and  in- 
sensible, with  stertorous,  or  hissing  respiration,  somewhat  resembling 
coma  or  asphyxia,  and  which  may  soon  prove  fatal ;  or  she  may  be 
unconscious  and  restless,  throwing  herself  about  in  the  bed,  until  the 
next  convulsive  paroxysm,  as  in  the  appoplectiform  eclampsia. 

Most  commonly  the  duration  of  the  convulsion  does  not  exceed  five 
or  ten  minutes,  while  the  intervals  may  extend  to  even  twelve  hours 
in  some  cases,  and  but  a  few  minutes  in  others. 

When  convulsions  occur  in  the  pregnant  female,  it  is  seldom  that 
she  will  complete  the  full  term,  and  the  child  will  be  still-born,  and 
frequently  putrid;  probably  the  paroxysms  may  at  times  be  caused  by 
the  dead  child  acting  as  a  foreign  irritant  to  the  uterus,  its  death  hav- 
ing taken  place  previous  to  the  attack.  Occasionally  the  spasms  cease 
spontaneously,  without  endangering  pregnancy ;  but  more  frequently 
uterine  contractions  are  aroused,  which  generally  expel  the  child, 
and  this  may  happen  without  any  consciousness  on  the  part  of  the 
mother. 

If  the  convulsions  come  on  before  the  occurrence  of  labor  pains,  at 
the  full  period,  they  usually  cause  dilatation  of  the  os  uteri ;  and  the 
uterine  contractions  which  may  follow,  will  be  feeble,  irregular,  and 
apparently  spasmodic,  often  alternating  with  the  convulsive  paroxysm. 


COMPLICATED    LABOR PUERPERAL    CONVULSIONS.  561 

During  labor,  there  may  or  may  not  be  a  suspension  of  the.  contrac- 
tions of  the  uterus;  but  more  commonly  it  participates  in  the  general 
spasmodic  irritability,  and  contracts  powerfully,  effecting  delivery 
without  the  patient  being  aware  of  it.  The  paroxysm  usually  ensues 
just  upon  the  return  of  uterine  action,  though  not  always  with  each 
pain.  Generally,  the  ordinary  character  of  the  pains  are  not  changed 
by  the  convulsions,  and  the  labor  proceeds  regularly,  unless  hastened 
by  art.  Not  unfrequently,  however,  the  action  of  the  uterus  becomes 
inefficient,  and  the  delivery  must  be  artificially  completed. 

When  puerperal  convulsions  occur  during  labor,  they  most  fre- 
quently cease  when  delivery  is  effected,  or  soon  after,  unless  they 
prove  fatal;  and  the  patient  is  generally  left  with  a  strong  tendency 
to  metritis  and  peritonitis. 

Puerperal  convulsions  may  terminate  by  recovery;  by  developing 
some  other  disease,  as  paralysis,  cerebral  lesions,  mania,  epilepsy, 
rupture  of  the  uterus,  metritis,  peritonitis,  etc.;  or  by  death. 

The  recovery  may  take  place  rapidly,  especially  when  the  par- 
oxysms have  been  few  and  of  a  mild  character,  or  it  may  be  tedious 
and  for  a  long  time  uncertain  ;  the  intellectual  faculties  very  gradually 
returning  to  their  normal  condition,  the  memory  being  excessively 
debilitated  or  destroyed,  as  well  as  the  hearing  and  sight.  This  de- 
rangement may  continue  for  a  day  or  two,  or  may  extend  to  several 
months  before  complete  restoration  takes  place. 

When  other  diseases  are  occasioned  by  the  convulsions,  the  patient 
may  ultimately  recover,  but  generally  with  impaired  health  for  the 
remainder  of  her  life;  and  frequently  these  diseases  contribute  to  a 
more  or  less  speedy  fatality.  Death  most  usually  occurs  when  the 
paroxysms  are  of  great  intensity  and  long  duration,  with  short  inter- 
vals between  them,  and  especially  in  those  cases  where  the  female  re- 
mains motionless  and  unconscious  during  the  intermissions.  It  may 
be  caused  by  effusions  on  the  brain,  or  by  a  too  prolonged  and  com- 
plete suspension  of  respiration;  also  by  a  rupture  of  the  uterus. 

The  above  description  of  symptoms,  together  with  the  preceding 
tables  for  distinguishing  the  attack  from  hysteria,  apoplexy,  and 
epilepsy,  will  render  it  unnecessary  to  detail  any  further  diagnosis. 

PROGNOSIS. — This  is  undoubtedly  an  extremely  fatal  disease,  the 
most  favorable  statistics  showing  that  one-fourth  of  those  who  have 
been  attacked  by  it  were  lost.  But  the  practitioner  may  generally  be 
enabled  to  form  a  prognosis,  somewhat  approximating  positiveness, 
by  ascertaining,  if  possible,  the  cause  that  produced  the  attack,  and  by 
36 


562  KING'S  ECLECTIC  OBSTETRICS. 

observing  the  period  at  which  it  occurs,  and  the  progress  and  charac- 
ter of  the  symptoms. 

If  the  paroxysms  are  very  severe  and  of  long  duration,  the  intervals 
being  short,  and  no  return  of  consciousness,  the  patient  lying  in  a 
state  of  stupor,  with  stertorous  brealhing,  she  will  be  in  a  very  critical 
situation,  and  more  especially  if  she  be  insensible  to  the  application 
of  stimulants.  The  longer  the  duration  of  the  intervals,  and  the  more, 
perfect  and  rapid  the  return  of  consciousness,  the  more  favorable  will 
be  the  case,  notwithstanding  the  severity  of  the  paroxysms.  And  the 
milder  the  convulsions,  with  the  last  named  character  of  intervals,  the 
less  will  be  the  danger. 

Females  whose  nervous  systems  are  extremely  susceptible,  who  are 
hysterical  or  subjects  of  epilepsy,  or  whose  minds  are  very  sensitive, 
are  less  apt  to  have  formidable  attacks  than  those  who  are  disposed  to 
apoplexy  or  coma,  or  who  are  laboring  under  serous  infiltrations. 

Convulsions  occurring  during  pregnancy,  or  during  labor,  are  more 
dangerous  than  those  which  take  place  only  after  delivery ;  and  when 
they  occur  early  in  labor,  before  the  parts  are  sufficiently  dilated  to 
admit  of  the  ready  expulsion  of  the  uterine  contents,  they  are  less 
favorable  than  toward  the  termination  of  the  delivery,  when  this  may 
be  effected  either  naturally  or  artificially.  They  are  likewise  more 
fatal  among  primi paras. 

•  When  the  convulsions  come  on  during  the  last  stage  of  labor,  and 
continue  equally  strong  after  the  delivery,  whether  this  has  been 
effected  naturally  or  artificially,  the  case  is  extremely  dangerous;  but 
if  the  patient  falls  into  a  gentle  sleep,  with  an  arrest  of  the  paroxysms, 
after  the  expulsion  of  the  uterine  contents,  they  seldom  return,  and 
convalescence  ensues.  After  the  delivery  and  the  disappearance  of 
the  convulsions,  the  practitioner  must  carefully  watch  the  patient,  in 
order  to  guard  her  against  any  subsequent  abdominal  inflammations, 
more  especially  if  puerperal  peritonitis  be,  at  the  time,  a  prevailing 
complaint. 

The  maternal  disorder  necessarily  exerts  an  unfavorable  influence 
upon  the  child,  and  we  find  that  the  major  part  are  either  still-born, 
or  die  in  a  few  days  after  birth  of  convulsions,  having,  probably,  while 
in  utero,  received  the  germ  of  the  disease  through  the  mother's  blood. 

M.  Bourneville,  who  has  investigated  this  subject,  states  that  in 
uremia  poisoning,  there  is  a  progressive  and  considerable  lowering  of 
the  temperature,  which  increases  as  death  approaches,  and  which 
attains  its  maximum  when  this  occurs,  even  to  41°  (105°  8'  F.);  while 


COMPLICATED    LABOR PUERPERAL    CONVULSIONS.  563 

in  puerperal  eclampsia  the  temperature  continues  to  rise  from  its  com- 
mencement to  its  termination,  during  coma,  and  in  the  intervals 
between  the  paroxysms,  diminishing  only  with  the  disappearance  of 
the  attack;  descending  at  the  moment  of  death  even  to  28°  V  (82°  5' 
F.).  If  the  coma  diminishes  in  eclampsia,  or  ceases  entirely,  and  the 
temperature  subsides,  the  prognosis  is  favorable,  and  vice  versa.  In 
cerebral  hemorrhage,  there  is  at  first  a  lowering  of  the  temperature, 
followed  by  an  elevation.  Epileptic  attacks  elevate  the  temperature, 
which  is  not  effected  by  hysteria.  However,  further  investigations 
are  required. 

PATHOLOGY. — Post-mortem  examinations  have  shed  but  little 
light  upon  the  nature  of  puerperal  convulsions,  no  appreciable  anatom- 
ical lesions  having  been  found — no  traces  of  injection  nor  changes  in 
the  character  of  the  tissues. 

Sometimes  a  serous  effusion  has  been  observed  in  the  ventricles,  or 
arachnoid  cavity,  and  perhaps  a  slight  congestion  of  the  encephalic  ves- 
sels; but  these  are  viewed  as  secondary  lesions,  being  merely  the 
effects  of  the  convulsions,  when  the  cerebral  congestion  is  very  great. 
The  heart  is  commonly  empty  and  relaxed,  the  lungs  pale,  and  occa- 
sionally fluid  has  been  met  with  in  the  pleura,  or  pericardium ;  traces 
of  peritoneal  inflammation  have  likewise  been  observed. 

In  considering  the  cause  of  this  disease,  and  the  morbid  conditions 
resulting  therefrom,  the  words  of  Leishman  might  be  quoted:  "That 
albuminuria  and  puerperal  eclampsia  are  mutually  dependent  upon 
eacli  other,  or,  at  least,  are  of  simultaneous  occurrence  in  the  vast 
majority  of  all  cases,  is  an  assertion  not  likely,  in  these  days,  to  be 
seriously  controverted.  But  it  is  by  no  means  agreed,  as  to  the  albu- 
men and  the  paroxysm,  which  is  the  cause  and  which  the  effect.  Ac- 
cording to  Braun,  and  those  who  support  his  views,  the  albumen 
appears  in  the  urine  as  the  result  of  that  inflammatory  affection  of  the 
kidney  commonly  known  as  Bright's  disease.  As  a  result  of  this,  the 
blood  is  poisoned  with  excrementitial  elements  of  the  urine,  and  espe- 
cially with  urea.  The  experiments  and  researches  of  Frerichs  have 
conclusively  shown  that  the  presence  of  urea  in  the  blood,  even  in 
considerable  quantity,  does  not  give  rise  to  eclampsia;  and  the  con- 
clusion which  he  has  reached  is,  that  the  active  poison  is  the  carbonate 
of  ammonia,  produced,  as  he  assumes,  by  the  decomposition  of  the 
urea;  which  must,  therefore,  be  acted  upon  by  some  particular  fer- 
ment, the  nature  of  which  has  yet  to  be  discovered  by  the  pathological 
chemist.  Frerichs  does  not  admit  the  essentially  inflammatory  nature 


564  KING'S  ECLECTIC  OBSTETRICS. 

of  the  disease;  at  least,  he  appears  to  do  so  only  to  a  limited  extent, 
when  he  assumes,  in  explanation  of  the  formation  of  the  hyaline  tube- 
casts,  that  the  inflammatory  theory  can  only  hold  good  in  so  far  as  the 
exudation  of  blood  plasma  is  connected  with  a  paralytic  dilatation  of 
the  capillaries.  Braun,  however,  broadly  maintains  that  the  disease 
is  of  inflammatory  origin,  and  that  the  nature  of  the  morbid  process  is 
identical  with  that  of  Bright's  disease. 

"The  other  theory  is  that  held  by  those  who,  while  admitting  the 
existence  of  albumen  in  the  urine,  as  an  essential  phenomenon,  assert 
that  this  is  the  effect  of  eclampsia,  and  not  its  cause — which  is,  by 
them,  supposed  to  be  the  result  of  some  blood  disease,  or  of  some 
blood  poison  hitherto  unknown  to  science.  And  certainly  the  fact 
that,  in  so  many  instances,  the  convulsions  precede  the  albuminuria, 
lends  some  confirmation  to  this  view." 

Lusk  quotes  Seyfert  on  this  subject,  in  addition  to  his  own  views,  as 
follows : 

"  1st.     That  convulsions  may  occur  without  albuminuria. 

"  2d.  That  the  albuminuria  is  in  many  cases  the  effect  and  not  the 
cause  of  the  convulsions. 

"  3d.  That  in  many  fatal  cases  the  kidney-lesions  were  absent  or 
wholly  insignificant. 

"4th.  That  convulsions  are  rare  in  chronic  Bright's  disease,  which 
had  existed  prior  to  pregnancy. 

"  5th.  That  in  true  uraemia,  such  as  necessarily  is  produced  by  the 
suppression  of  urine  when,  in  uterine  cancer,  the  ureters  are  invaded, 
convulsions  do  not  occur. 

"  That,  in  the  main,  these  propositions  are  correct,  hardly  admits 
of  question.  But,  in  drawing  conclusions  from  these,  unnecessary 
stress  is  laid  upon  the  presence  or  absence  of  albumen  in  the  urinary 
secretion.  It  is  the  renal  insufficiency,  it  should  be  fixed  in  the  mind, 
and  not  the  albuminuria,  which  causes  urasmia  and  convulsions.  The 
mere  absence  of  albumen  from  the  urine  does  not  even  exclude  the 
existence  of  Bright's  disease.  Braun  is  careful  to  note  that,  in  certain 
cases  of  fatal  eclampsia,  in  spite  of  the  absence  of  albuminuria,  the 
post-mortem  examination  revealed  amyloid  degeneration  of  the  kidneys 
and  of  the  heart-structures ;  and  again,  in  others,  of  atrophy  of  both 
kidneys,  where  the  dropsy,  and  the  albumen,  and  casts,  which  had 
been  present  earlier  in  pregnancy,  had  entirely  disappeared  at  the 
moment  the  convulsions  occurred.  Bailly  has  shown  that  not  rarely 
albuminuria  in  pregnant  women  may  disappear  for  several  hours,  and 


COMPLICATED    LABOR — PUERPERAL    CONVULSIONS.  565 

then  re-appear  once  more;  so  that  it  is  possible  for  an  examination  to 
be  made  during  the  short  period  when  the  urine  ceases  to  be  albu- 
minous." 

TREATMENT. — The  indications  of  treatment  in  puerperal  con- 
vulsions are,  1st,  to  subdue  spasmodic  action;  2d,  to  overcome  cereb- 
ral congestion,  and  equalize  the  circulation ;  3d,  to  hasten  the  delivery, 
when  labor  is  on,  by  the  most  appropriate  means,  provided  the  par- 
oxysms are  not  subdued ;  and,  4th,  to  prevent  any  secondary  attacks, 
and  gradually  strengthen  the  patient. 

For  the  fulfilling  of  the  first  indication,  bleeding  to  the  amount  of 
from  thirty  to  sixty  ounces,  and  taken  in  a  full  stream  from  the  arm 
or  temporal  artery,  was  the  treatment  formerly  recommended  ;  indeed  it 
was  the  remedy,  and  tlie  principal  remedy,  upon  which  the  majority  of  prac- 
titioners at  one  time  relied.  Prof.  King  remarks  that  in  former  years  he 
was  in  the  habit  of  bleeding  in  these  cases,  and  with  various  results; 
but,  in  an  experience  covering  a  large  number  of  cases,  he  became 
thoroughly  convinced  that  many  of  the  unsuccessful  cases  could  have 
been  saved  by  different  treatment,  and  that,  in  the  successful  ones,  the 
bleeding  eifected  but  very  little  service.  Many  practitioners  still 
adhere  to  this  old  treatment,  and  recommend  it  in  the  cases  under 
consideration ;  but  what  benefit  can  any  thinking  man  consider  to  be 
the  consequence  of  excessive  bleeding,  when,  at  farthest,  but  only  one 
out  of  every  four  patients  is  saved?  Beside,  those  who  are  saved  by 
these  excessive  depletions  rarely  have  a  complete  restoration  to  health 
subsequently,  but  linger  for  a  longer  or  shorter  time,  under  some 
malady  resulting  from  the  bleeding,  and  which  ultimately  occasions 
their  death.  These  large  bleedings  seriously  injure  the  vital  force, 
and,  I  believe,  frequently  prevent  recovery  where  it  might  otherwise 
have,  taken  place.  The  treatment  which  I  shall  now  r-ecommend  to 
the  profession,  in  puerperal  convulsions,  will  be  found  fully  as  suc- 
cessful as  the  depletive  one  just  referred  to,  and  vastly  superior  to  it, 
inasmuch  as  it  does  not  cause  any  serious  affections  from  sudden, 
excessive,  and  persistent  prostration  of  the  vascular  and  nervous 
systems. 

The  former  treatment,  used  and  recommended  by  the  eclectics  of 
the  olden  time,  in  puerperal  eclampsia,  consisted  almost  exclusively 
in  the  internal  use  of  Gelsemium,  and  the  compound  tincture  of 
Lobelia  and  Capsicum  per  rectum.  This  antispasmodic  compound 
was  also  given  in  large  doses  internally,  in  cases  where  the  patient 
was  able  to  swallow.  It  was  claimed  that  a  paroxysm  could  be 


566  KING'S  ECLECTIC  OBSTETRICS. 

frequently  shortened  in  its  duration  by  the  administration  of  the  com- 
pound while  it  was  on;  and  that  its  use  at  such  times  did  not  contra- 
indicate,  nor  interfere  with,  the  employment  of  Gelsemium  during  the 
intervals,  should  this  be  deemed  necessary.  The  continued  use  of  the 
compound  tincture  of  Lobelia  and  Capsicum,  in  this  manner,  was 
advised,  until  a  positive  influence  had  been  exerted  upon  the  muscular 
system  of  the  patient,  rendering  it  powerless)  when  its  further  use;  was 
not  required,  unless  there  should  be  a  return  of  the  paroxysm  ;  how- 
ever, the  patient  should  always  be  placed  under  its  relaxing  influence 
as  soon  as  practicable.  Frequently,  it  is  cited,  this  agent  will  not 
only  overcome  the  spasmodic. tendency  of  the  voluntary  muscles,  but 
will  at  once  relieve  cerebral  congestion,  favor  dilatation  of  the  os 
uteri,  and  thus  aid  in  hastening  delivery  when  labor  is  on,  and  also 
prevent  any  disposition  to  subsequent  abdominal  inflammations. 

Counter- irritation  to  the  extremities  was  also  a  common  adjunct  to 
the  old  treatment,  as  well  as  the  application  of  cups  to  the  back  of  the 
neck  and  lumbar  region,  and  ligatures  to  the  thighs  to  prevent  too 
much  blood  from  being  thrown  into  the  trunk  and  head.  This  was 
the  line  of  treatment  pursued  for  years  in  puerperal  convulsions;  and 
while  it  would,  no  doubt,  prove  quite  unsatisfactory  to  the  majority 
of  physicians  of  the  present  time,  it,  nevertheless,  gave  decidedly  bet- 
ter results  than  bleeding — a  popular  treatment  of  the  time  with  many 
physicians. 

The  present  treatment  does  not  include  a  large  number  of  remedies; 
probably  a  half-dozen  would  include  the  entire  list.  Physicians  vary 
in  the  selection  of  agents  for  the  treatment  of  this,  as  in  other  diseases; 
each  having  a  preference  of  one  or  two  of  the  usual  remedies  that  have 
given  satisfactory  results,  and  with  which  he  successfully  treats  his 
cases. 

I  have  always  regarded  Chloroform  as  deserving  first  place  in  the 
consideration  of  remedies — that  is,  during  labor,  the  woman  being  in 
spasms.  Administer  it  at  once,  to  the  extent  of  anesthesia  sufficiently 
profound  to  produce  relaxation  and  overcome  spasmodic  action.  As 
soon  as  the  convulsive  action  begins  to  subside,  Morphia  should  be 
administered — a  hypodermic  injection  of  one-third  to  one-half  grain, 
gradually  substituting  the  Morphia  for  the  Chloroform.  If  after  the 
first,  or  even  the  second,  injection  of  Morphia,  there  should  develop 
symptoms  of  a  return  of  the  convulsions,  again  allow  the  patient  to 
inhale  the  Chloroform  as  at  first,  repeating  the  Morphia  every  half  to- 
one  hour  until  all  indications  of  spasmodic  action  have  disappeared. 


COMPLICATED    LABOR — PUEIiPERAL    CONVULSIONS.  567 

By  many,  Morphia  is  believed  to  stand  first  among  the  remedies  in 
puerperal  convulsions,  its  action  being  direct  upon  the  spinal  center, 
and  thus  overcoming  the  perverted  innervation.  No  doubt  many  cases 
are  cured  by  the  use  of  Morphia  alone ;  however,  my  observation  has 
been,  where  the  convulsions  are  severe,  with  general  spasmodic  action, 
that  quicker  results  follow  the  inhalation  of  Chloroform  than  the  use 
of  any  other  remedy ;  but  it  should,  I  believe,  be  discontinued  as  soon 
as  the  spasms  can  be  held  in  subjection  with  other  agents,  and,  for 
this  second  effect,  Morphia  hypodermically  is  the  remedy  that  will 
give  the  most  satisfactory  results,  and  upon  which  I  place  the  greatest 
reliance.  This  treatment,  I  believe,  if  given  early,  and  persisted  in, 
will  overcome  as  many  of  the  curable  cases,  in  as  short  a  time,  as  any 
other  line  of  treatment  that  could  be  prescribed. 

Chloral  stands  very  high  in  the  estimation  of  many  as  a  curative 
agent  in  this  trouble.  Given  in  large  doses,  an  anesthetic  effect  is- 
claimed  for  it,  and  to  this  end  it  should  be  given,  rather  than  in  the 
usual  dose  as  a  sedative.  M.  Charpentier,  after  observing  the  results- 
of  bleeding,  Chloral,  and  other  anesthetics,  as  agents  in  the  treatment 
of  eclampsia,  contrasts  the  effects  as  follows: 

Mortality  in  cases  treated  by  bleeding,        .        .        35  per  cent. 
"  anesthetics,       .        .11        " 

Chloral  is  often  given  with  Bromide  of  Potassium.  Several 
physicians  of  my  acquaintance  report  the  most  gratifying  results  from 
the  use  of  a  combination  of  grs.  xxx  of  each  of  these  agents,  admin- 
istered per  rectum,  to  be  repeated  according  to  the  severity  of  the 
case,  and  the  effect  produced.  Some  practitioners,  after  quieting  the 
convulsions  in  the  beginning  with  Chloroform,  substitute  the  Bromide 
and  Chloral  instead  of  Morphia. 

In  some  cases  the  indication  for  Gelsemium  appears  to  stand  out 
clearly,  and  where  the  patient  is  able  to  swallow,  it  may  be  given  with 
beneficial  results.  I  have  noticed  the  specific  indications  for  this 
agent,  it  seems  to  me,  more  often  in  cases  of  eclampsia  occurring  after 
delivery,  than  at  any  other  time.  Desirable  results  might  be  obtained 
by  administering  it  in  combination  with  other  remedies,  in  cases 
where  it  was  especially  called  for. 

Another  remedy  that  was  thoroughly  tested,  both  in  hospital  and 
private  practice,  a  few  years  since,  was  Tr.  Veratrum  Vir.  It  was 
supposed,  by  some  of  the  more  sanguine  champions  of  this  agent,  that 
in  it  almost  a  specific  for  the  disease  had  been  discovered.  As  to  the 


568  KING'S  ECLECTIC  OBSTETRICS. 

action  of  Veratrum,  Lusk  quotes  Dr.  Kenyon,  who  .-ays:  "The  drug 
is  quickly  al)sorl)C(l,  and  enters  the  circulation  rapidly.  It  enters  the 
vasa  vasorum,  and  through  them  impairs  the  sensibility  of  the  vaso- 
motor  nerves,  the  blood-vessels  thus  losing  their  tonicity  and  power 
of  contraction."  It  is  claimed  by  most  writers  that  very  large 
doses  are  necessary,  in  administering  Veratrum,  in  order  to  produce 
the  effect  desired;  by  some,  fifteen  drop  doses  every  fifteen  or  twenty 
minutes  is  suggested;  others  claim  that  sixty  to  one  hundred  drops 
every  thirty  or  sixty  minutes  will  answer  a  better  purpose.  The  toxic 
effect  of  the  drug  is  manifested  by  vomiting — and  which  is  usually 
provoked  when  pushed  to  the  full  dose.  The  poisonous  effect  is 
counteracted,  it  is  claimed,  by  the  morbific  principle  of  the  disease ; 
thus  the  theory  that  large  doses  can  be  safely  administered,  and  should 
be  continued  until  vomiting  is  induced. 

Physostigma  may  also  be  classified  among  the  remedies  to  be 
thought  of  in  the  disease  under  consideration ;  its  use,  however,  in 
this  connection  has  been  quite  limited.  It  is  a  powerful  spinal  sed- 
ative, relaxing  the  capillaries  and  diminishing  the  circulation  in  the 
nerve-centers,  and  overcoming  the  active  hyperaBmia  present  with 
eclampsia.  It  would,  no  doubt,  prove  a  valuable  remedy  in  many 
cases.  It  should  be  further  tested,  and  its  action  carefully  studied. 
Prof.  Scudder,  in  writing  of  Physostigma,  says :  "  I  used  it  in  a  case 
of  puerperal  convulsions,  where  other  remedies  had  failed,  with 
marked  success."  As  to  dose,  he  says:  "The  dose  of  the  extract  will 
be  from  one-sixteenth  to  the  one-fifth  of  a  grain ;  of  a  good  tincture 
from  one  to  ten  drops." 

As  to  bleeding,  I  shall  give  it  no  further  consideration  as  a  remedy, 
feeling  that  it  should  be  ignored,  in  view  of  the  several  very  excellent 
remedies  we  now  possess,  as  well  as  the  fact  of  the  material  decrease 
in  the  death  rate  since  more  rational  remedial  measures  have  been 
substituted  for  it. 

Perhaps  cups  to  the  head,  nape  of  the  neck,  and  lumbar  region, 
which  have  been  advised  by  some,  may  be  advantageously  employed, 
but  they  can  not  be  readily  applied  during  the  paroxysms,  and  during 
the  intervals  I  would  prefer  the  means  already  named.  I  have  never 
used  cups  in  this  disease. 

All  these  means  will  not  be  required  in  every  instance,  but  when 
the  convulsions  are  intense,  with  excessive  cerebral  congestion,  the 
plan  of  treatment  as  suggested,  or  the  selection  of  some  of  the  other 
agents  mentioned,  should  be  promptly,  energetically,  and  persistently 


COMPLICATED    LABOR PUERPERAL    CONVULSIONS.  569 

brought  to  bear  upon  the  disease;  and  it  must  be  truly  a  desperate 
case  which  can  not  be  overcome  by  timely  application.  Of  course, 
no  cure  can  be  expected  where  there  is  considerable  effusion  on  the 
brain;  but  as  we  can  not  determine  with  positiveuess  whether  this 
has  occurred  or  not,  we  should  be  persevering  in  our  efforts,  however 
hopeless  the  case  may  appear. 

During  the  continuance  of  the  attack  the  bladder  should  be  attended 
to,  and  evacuated  by  the  catheter  on  the  occurrence  of  an  interval,  if 
it  becomes  too  much  distended;  and  after  the  delivery  of  the  child  be 
careful  that  the  placenta  is  not  retained. 

Frequently,  during  labor,  when  the  child  is  delivered,  the  convul- 
sions cease,  and  from  a  knowledge  of  this  fact  some  writers  have 
recommended  the  hastening  of  the  delivery  as  a  part  of  the  treatment, 
even  when  the  os  uteri  is  rigid  and  tindilated.  Others  claim  that  such 
interference  is  never  justifiable,  and  the  consequence  has  been,  that 
more  females  have  been  destroyed  by  officious  and  forcible  delivery 
than  have  been  lost  by  leaving  them  to  the  natural  resources  of  the 
system. 

It  is  far  better,  says  Blundell,  that  the  woman  should  die  convulsed 
in  the  hands  of  nature,  than  that  she  should  perish  by  the  cruel  and 
savage  operation  of  rough  and  unskillful  midwifery. 

Lusk,  in  closing  the  chapter  on  Puerperal  Eclampsia  in  his  work 
on  obstetrics,  offers  the  following : 

"  As  convulsions  which  occur  after  the  advent  of  labor  have  a  tend- 
ency to  recur  so  long  as  the  labor  continues,  and  in  the  larger  propor- 
tion of  cases  cease  after  the  birth  of  the  child,  every  obstetrical 
resource  compatible  with  the  safety  of  the  mother  should  be  employed 
to  hasten  delivery.  In  the  early  part  of  the  first  stage,  the  pains,  if 
sluggish,  should  be  stimulated  by  catheterization  of  the  uterus. 

"Braun  advocates  rupturing  the  membranes,  as  he  claims  that  the 
escape  of  the  amniotic  fluid  often  diminishes  the  frequency  and 
violence  of  the  convulsions.  The  water-bags  of  Dr.  Barnes,  if  neces- 
sary, should  be  used  to  promote  the  dilatation  of  the  cervix. 

"  After  the  first  stage  is  completed,  if  no  mechanical  disproportion 
exists  between  the  head  and  the  pelvis,  a  careful  attempt  to  extract 
the  child  with  forceps  should  be  made.  Every  precaution  should 
be  used  to  avoid  injuring  the  soft  parts.  Obstetrical  aid  is  only 
warrantable  where  it  can  be  employed  without  detriment  to  the 
mother." 


570  KING'S  ECLECTIC  OBSTETRICS. 

When  the  accoucheur  has  faithfully  employed  the  various  means 
recommended  for  the  removal  of  puerperal  convulsions  during  labor, 
and  no  favorable  impression  has  been  made  upon  them  after  a 
reasonable  time  has  progressed,  he  may  then  ascertain  whether  the 
condition  of  the  parts  is  favorable  for  an  artificial  delivery;  indeed,  it 
is  proper  for  him  to  examine  from  time  to  time  while  the  fits  last, 
lest  the  child  be  expelled  unconsciously;  also,  to  learn  how  the  labor 
is  progressing,  and  what  may  be  the  influence  exerted  upon  it  by  the 
spasms.  But  he  must  be  extremely  cautious  how  he  interferes  with 
the  delivery,  lest  his  attempts  prove  more  fatal  than  the  disease.  It 
is  not  always  that  the  evacuation  of  the  uterus  is  followed  by  a  cessa- 
tion of  the  convulsions;  and  not  (infrequently  these  become  aggra- 
vated by  the  attempts  made  to  hasten  the  labor.  When  the  female 
manifests  periodically  much  uneasiness,  moaning,  and  groping  and 
writhing  about,  it  is  indicative  of  uterine  contractions  taking  place ; 
and  when  the  head  is  at  the  perineum,  she  will  frequently  be  observed 
to  strain. 

In  a  case  where  interference  is  indicated  by  the  severity  of  the 
attack  and  its  unyielding  character,  if  the  os  uteri  be  found  rigid,  or 
soft  and  dilatable,  but  not  fully  dilated,  the  accoucheur  may  be  able 
to  aid  the  dilatation  by  sweeping  the  finger  about  the  os,  or  by  such 
other  means  as  heretofore  recommended;  however,  the  effect  on  the 
patient,  of  such  means,  should  be  carefully  watched.  Convulsive 
action  may  be  aggravated  or  increased  by  reflex  excitation,  the  result 
of  slight  irritation — the  effect,- sometimes,  of  the  finger  coming  in  con- 
tact with  the  uterus.  Consequently,  if  an  attempt  to  promote  dilata- 
tion should  cause  a  return  of  the  spasms,  or  other  alarming  symptoms, 
he  must  wait;  he  must  be  patient,  until  complete  dilatation  is  nearly 
accomplished,  when  he  may  rupture  the  membranes — a  course  which 
frequently  expedites  the  labor — but  he  must  not  attempt  turning, 
even  should  it  be  a  breech  presentation :  turning  is  a  very  hazardous 
measure  in  convulsions,  but  few  females  having  recovered  where  it 
has  been  performed.  Mai-presentations,  according  to  the  observa- 
tions of  accoucheurs,  are  very  rarely  met  with  in  puerperal  convul- 
sions. If,  however,  the  head  be  found  in  the  pelvis,  and  within  reach 
of  the  forceps,  they  may  be  immediately  applied  and  the  delivery  ter- 
minated in  this  manner.  But  no  attempts  at  artificial  delivery  must 
be  made  while  the  paroxysms  are  on,  unless  the  patient  lies  in  a 
motionless  and  comatose  condition;  else,  irreparable  injury  to  the 
soft  parts  may  accrue,  owing  to  the  violent  struggles  of  the  patient : 
and  should  a  fit  come  on  during  the  application  of  the  blades,  they 


COMPLICATED    LABOR PUERPERAL    CONVULSIONS.  571 

must  be  immediately  withdrawn,  to  avoid  being  forced  through  the 
walls  of  the  vagina  or  uterus. 

If  the  head  be  found  steadily  advancing,  without  any  delay  in  its 
progress,  artificial  aid  will  not,  as  a  rule,  be  required.  Sometimes  the 
head  may  be  so  firmly  fixed  in  the  pelvis  as  to  resist  all  justifiable 
efforts  to  remove  it  with  the  forceps;  here 'the  perforator  would  be 
indicated,  and  should  be  used  as  heretofore  advised,  and  if  delivery  by 
the  forceps  be  impossible,  operate  without  further  delay.  However, 
the  judicious  practitioner  will  be  guided  more  by  the  circumstances 
of  the  case,  than  by  any  specific  rules. 

After  the  delivery,  means  to  prevent  any  secondary  attacks,  and 
gradually  restore  the  tone  of  the  system,  will  be  called  for,  when  the 
convulsions  have  ceased. 

Whatever  may  be  the  condition  of  the  patient  at  this  time — whether 
she  complains  of  pain  in  the  head  or  abdomen,  or  whether  she  be 
maniacal — the  apartment  which  she  occupies  must  be  darkened,  the 
greatest  stillness  must  be  observed,  and  every  source  of  irritation 
removed,  that  she  may  be  kept  as  quiet  as  possible.  The  lightest 
nourishment  only  should  be  permitted  at  first;  afterward,  as  her 
strength  improves,  it  should  be  more  substantial,  gradually  increasing 
the  diet  as  convalescence  progresses.  The  bowels  and  bladder  should 
be  attended  to,  regulating  the  former  either  by  injections  or  internal 
laxatives,  as  circumstances  wrill  allow. 

Symptoms  of  secondary  attacks  may  necessitate  the  continued 
administration  of  some  of  the  remedies  used  in  the  beginning.  An 
occasional  dose  of  Morphia,  may  be  called  for.  Sulphate  of  Quinia 
may  be  given  in  some  case£ '  Gelsemium  should  be  administered 
where  there  is  jerking,  or  inclination  to  spasmodic  action.  Extreme 
nervousness  calls  for  Pulsatilla.  The  indication  for  Rhus  Tox.  will 
sometimes  be  present  also. 

It  will  be  wrell  to  use  local  antiseptic  precautionary  measures,  as 
vaginal  injections  of  Hot  Water,  in  which  has  been  dissolved  a  small 
portion  of  Chlorate  of  Potassium,  or  Borax.  This  should  be  repeated 
twice  a  day,  until  all  danger  has  passed. 

Dr.  J.  S.  McClelland,  in  a  recent  paper  on  Puerperal  Eclampsia, 
made  the  following  report  of  treatment,  mortality,  etc.,  as  gathered 
from  a  number  of  eclectic  physicians: 

"  Of  the  twenty  physicians  to  whom  I  sent  blanks,  thirteen  re- 
sponded. Those  thirteen  reported  7,190  births,  with  28  cases  of 
eclampsia;  or  1  to  256. 


572  KING'S  ECLECTIC  OBSTETRICS. 

"Of  the  28  case's,  22,  or  nearly  SO  per  cent.,  recovered;  and  6,  or 
20  per  cent.,  died. 

"Of  the  cases  recovering,  we  find  that  six  women  convulsed  during 
or-iminediately  preceding  labor;  three  at  from  six  to  eight  months; 
two  after  labor  was  completed;  and  one  as  late  as  twelve  hours  after 
labor  was  completed;  and  in  ten  cases  the  time  not  given,  out,  from 
the  above,  it  would  be  safe  to  say  that  four  of  the  ten  occurred  during 
labor. 

"Taking  the  fatal  cases,  we  find  that  in  five  the  convulsion  came  on 
before  or  during  labor.  In  the  remaining  case  the  time  that  the  con- 
vulsion came  on  is  not  given. 

"Those  physicians  reporting  fatal  cases  have,  together,  21  cases  of 
convulsions,  of  which  nearly  30  per  cent.  died.  One  physician 
reported  1  fatal  case  in  7;  one,  2  in  6;  another,  1  in  4;  and  another, 
2— all  he  had. 

"  Enumerating  the  remedies  used  in  the  treatment  of  the  cases 
reported,  we  find  that  the  list  includes  Morphine,  Gelsemium,  Yerat- 
rum  Vir.,  Chloroform,  Antispasmodic  Tincture,  Chloral,  Physostigma, 
Lobelia,  Bromide  of  Potassium,  Ergot  and  Bleeding. 

"Taking  each  remedy  in  order,  we  find  that  Sul.  of  Morphia  was 
used  in  ten  cases  recovering,  and  in  five  of  the  fatal  cases.  Four  of 
the  cases  recovering  were  given  Morphia  alone,  in  one  it  was  com- 
bined with  Chloral,  and  with  bleeding  in  one.  Morphia  was  not  used 
alone  in  any  of  the  fatal  cases. 

"  Gelsemium  was  used  in  nine  cases  recovering,  and  in  three  fatal 
cases.  In  four  of  the  cases  recovering  it  was  combined  with  Anti- 
spasmodic  Tincture;  in  two  cases  it  was  used  with  Chloral;  in  the 
other  three  cases  it  was  associated  with  two  or  more  other  remedies. 

"We  find  Veratrum  used  in  seven  cases  recovering,  and  in  four 
cases  that  died.  In  one  of  the  cases  recovering  it  was  used  with 
Chloroform  only,  but  never  alone.  In  the  fatal  cases  it  was  not  used 
alone. 

"  Chloroform  was  associated  with  other  remedies  in  ten  cases  re- 
covering, and  in  five  of  the  fatal  cases. 

"Antispasmodic  Tincture  was  used  in  conjunction  with  Gelsemium 
in  four  cases  recovering,  and  in  one  fatal  case. 

''  Chloral  Hydrate  was  used  alone  in  three  cases,  and  associated  with 
Bromide  of  Potassium  in  two  that  recovered  and  in  five  that  died. 

"Physostigma  was  used  alone  in  one  case  that  recovered. 

"  Lobelia  was  used  alone  in  one  fatal  case. 


COMPLICATED    LABOR — PUERPERAL    CONVULSIONS.  573 

"  Bromide  of  Potassium  was  given  with  Chloral  in  two  oases  recover- 
ing, and  with  Ergot  in  one  fatal  case. 

"Bleeding  was  done  in  three  cases,  two  of  which  proved  fatal. 
(The  first  of  the  fatal  cases  was  bled  before  the  physician  reporting 
saw  it;  the  other  was  bled  through  the  advice  of  an  allopath  who  was 
called  in  consultation.)  The  physician  reporting  the  case  that  recov- 
ered did  not  attribute  any  curative  properties  to  the  bleeding,  but 
wholly  to  the  Sul.  of  Morphia. 

"From  the  above  it  will  be  seen  that  Sul.  of  Morphia  and  Chloral 
were  used  alone  in  more  cases  recovering  than  any  other  remedies. 

"  Physostigma  was  not  used  often  enough  to  prove  its  value. 

"Gelsemium,  Vcratrum  and  Chloroform  follow  closely  after  Mor- 
phine and  Chloral.  Antispasmodic  Tincture  and  Bromide  of  Potas- 
sium, in  many  cases,  may  be  the  remedy." 


CHAPTER   XLII. 

TURNING,    OR    VERSION CEPHALIC    VERSION PODALIC   VERSION— 

THE    FILLET THE    VECTIS,    LEVER,    OR    TRACTOR- 
BLUNT    HOOK PLACENTAL    FORCEPS. 

ALL  operations  during  labor,  for  the  purpose  of  artificial  delivery, 
whether  manual  or  instrumental,  are  necessarily  accompanied  with 
more  or  less  danger,  *and  hence,  they  should  never  be  attempted,  for 
any  purpose  whatever,  unless  nature  is  found  incompetent  to  termi- 
nate the  delivery,  or,  when  absolutely  required  to  preserve  the 
mother's  life,  or  that  of  the  child,  when  the  mother's  life  is  in  a  hope- 
less situation. 

The  great  sacrifice  of  health  and  life,  among  females,  from  indis- 
criminate and  unjustifiable  interference,  has  led  some  practitioners  to 
set  aside  all  artificial  means  of  relief,  and  to  rely  entirely  on  un- 
assisted nature,  in  every  case  of  labor.  This,  however,  is  passing 
into  another  extreme,  and  is  decidedly  wrong;  aid  is  sometimes 
demanded,  and  then  it  must  be  given — to  withhold  it  would  be  crim- 
inal; and  it  is  among  these  cases  in  which  the  properly  educated 
accoucheur  distinguishes  himself  from  the  ignorant  pretender,  by  his 
calmness  and  prudence,  his  proper  selection  of  the  time  for  affording 
assistance,  as  well  as  of  the  means  to  be  used,  and  the  cautious  and 
skillful  employment  of  these  means. 


574  KING'S  ECLECTIC  OBSTETRICS. 

Let  the  student  remember,  that  in  no  ease  are  the  efforts  of  nature 
to  be  intermeddled  with,  either  by  manual  or  instrumental  operations, 
niilos  it  be  known  that  the  welfare  of  the  mother,  and  possibly  the 
life  of  the  child,  demands  it ;  the  woman  should  not  be  allowed  to 
suffer  extreme  exhaustion,  for  the  want  of  instrumental  interference, 
notwithstanding  the  fact  that  the  natural  efforts  may  be  sufficient  to 
complete  th.e  labor.  Prolapsus  of  the  uterus,  rupture  of  the  uterus, 
inversion  of  the  uterus,  profuse  hemorrhage,  peritonitis,  permanent 
dysmenorrhea,  laceration  of  the  vagina,  and  also  of  the  perineum,  etc., 
have  frequently  resulted  from  ill-timed,  injudicious,  and  unwarrantable 
endeavors  at  forwarding  the  delivery.  These  accidents  have  occurred 
in  the  practice  of  the  most  eminent  obstetricians  in  instances  where 
the  greatest  care  and  prudence  were  exhibited;  how  much  more  readily 
then  will  they  happen  in  the  practice  of  the  ignorant,  officious,  and 
unconscientious  practitioner?  Were  females,  or  their  husbands  and 
friends,  generally  aware  of  the  great  want  of  skill  and  knowledge 
in  this  department  of  medicine,  which  prevails  so  extensively  in  the 
profession,  and  which  is  based  upon  the  fact,  that  in  the  majority  of 
labors  the  unassisted  and  natural  resources  of  the  system  are  adequate 
to  the  task  of  completing  labor,  they  would  be  more  careful  and 
scrupulous  in  their  selection  of  obstetric  attendants,  and  by  this  means 
would  compel  students  to  be  more  attentive  to  the  means  of  becoming 
efficient  and  skillful.  I  do  not  refer  merely  to  a  want  of  knowledge 
and  practice  in  labors  actually  requiring  assistance,  but,  more  particu- 
larly to  those  in  which  no  aid  is  needed,  and  in  which  the  practitioner 
destroys  either  health  or  life,  by  vain  and  ignorant  displays  of  unwar- 
rantable manipulations. 

Among  the  operations  occasionally  required  during  labor,  and  to 
which  some  reference  has  been  made  in  the  preceding  p'ages,  that  of 
TURNING  or  VERSION,  may  be  noticed.  According  to  Churchill, 
49,323  cases  in  English  practice,  required  turning  in  190  instances,  or 
about  1  in  260 ;  37,479  cases  in  French  practice,  required  it  in  400 
instances,  or  about  1  in  93J;  21,516  cases  in  German  practice,  required 
it  in  337  instances,  or  about  1  in  64.  Making  927  cases  of  version 
out  of  108,318,  or  about  1  in  117.  In' 192  cases,  in  which  the  mor- 
tality to  the  mother  has  been  named,  12  died,  or  1  in  16.  In  565 
cases,  187  children  were  last,  or  nearly  1  in  3.  Some  allowance  must 
be  made,  however,  for  the  various  and  serious  accidents  which  render 
the  operation  necessary. 

There  are  two  modes  of  turning  mentioned  by  writers;  one,  the 
CEPHALIC  VERSION,  or  Version  by  the  Head,  in  which  the  head 


TURNING,    OR   VERSION — PODALIC    VERSION.  575 

is  brought  to  the  pelvic  brim ;  the  other,  PODALIC  VERSION",  or 
Turning  by  the  Feet,  in  which  delivery  by  the  feet  is  substituted  for 
that  by  the  original  presenting  part. 

CEPHALIC  VERSION,  has  been  recommended  at  various  times 
by  eminent  accoucheurs,  but,  heretofore,  it  has  not  proved  so  efficacious 
as  could  be  desired,  although  less  dangerous  to  the  child  than  podalic 
version,  and  hence  is  not  much  practiced.  It  has  been  advised  in  mal- 
positions of  the  vertex,  in  face  and*ear  presentations,  and  sometimes 
in  shoulder  presentations ;  but  where  prompt  delivery  is  demanded, 
turning  by  the  feet  is  preferred,  because  cephalic  version  as  ordinarily 
performed,  renders  the  delivery  more  tedious.  In  reply  to  objections, 
that  it  is  difficult  to  seize  the  head  firmly,  and  bring  it  to  the  brim, 
Velpeau  observes  :  "  1st,  it  is  not  always  very  difficult  to  seize  the 
head,  and  to  exert  considerable  force  upon  it ;  2dly,  if  the  waters  have 
not  long  been  discharged,  one  may  often  without  difficulty  seize  the 
vertex,  and  bring  it  to  the  center  of  the  brim,  however  far  it  may  have, 
been  distant ;  3dly,  that  in  general  it  is  better  to  force  the  head  to 
descend,  by  pushing  up  the  presenting  part,  than  by  bringing  down 
the  head ;  4thly,  that  delivering  by  the  breech  is  far  from  being  a 
simple  and  safe  operation;  as  regards  the  child,  it  is  less  so  than 
cephalic  version,  even  if  the  forceps  should  be  afterward  applied." 
Notwithstanding  this  reply,  there  is  much  weight  in  the  objections; 
and  attempts  to  push  up  the  presenting  part  will  frequently  induce 
such  violent  uterine  contractions  as  to  cause  the  operator  to  desist. 

In  cases  where  ordinary  cephalic  version  is  preferred,  the  bladder 
and 'bowels  should  be  emptied,  the  female  placed  upon  her  back,  the 
vagina  and  soft  parts,  as  well  as  the  hands  of  the  accoucheur,  well 
greased,  and,  to  relax  the  abdominal  walls,  the  legs  should  be  flexed, 
with  the  thighs  well  up  toward  the  abdomen.  Any  uterine  obliquity 
should  be  remedied.  The  hand  is  to  be  introduced  into  the  vagina 
and  uterus  in  the  same  manner  as  named  for  podalic  version.  Main- 
taining the  uterine  fundus  steadily  with  the  external  hand,  the  fetus 
may  be  manipulated  carefully  with  the  other  hand,  until  the  head  is 
brought  into  proper  position;  this  can  often  be  effected  without  passing 
the  whole  hand  into  the  uterus.  If  the  membranes  are  not  ruptured 
by  the  operation,  they  should  be  as  soon  as  it  is  terminated.  In  many 
cases  external  manipulation  will  greatly  aid  the  operation,  as,  where 
the  abdominal  and  uterine  walls  are  thin.  If  the  uterus  does  not 
promptly  contract  after  the  version  is  accomplished,  the  forceps  will 
be  required.  The  operation  is  readily  performed  in  some  instances, 
but  is  very  difficult,  if  not  quite  impossible,  in  others  where  it  is  indi- 
cated, and  would  seem  easy  of  execution. 


576  KING'S  KCLI-'.OTIC  OKSTKTIMCS. 

PODALIC  VERSION,  or  turning  by  the  feet,  is  the  operation 
generally  practiced  and  preferred  in  those  cases  where  a  change  of 
position,  or  prompt  delivery  is  required.  It  possesses  several  advan- 
tages as  well  as  disadvantages.  The  advantages  are,  that  the  accoucheur 
has  the  labor  more  completely  under  his  control,  and  can  deliver  or 
not.  as  the  case  may  require,  with  or  without  uterine  action  ;  it  is 
nearly  equal,  in  point  of  safety,  to  vertex  labors,  and  is  considered 
superior  to  any  other ;  it  is  frequently  the  only  method  by  which  to 
save  the  child's  life,  or  to  avoid  exvisceration ;  and  often  it  is  the  only 
chance  for  the  safety  of  the  mother.  Its  disadvantages  are,  that  the 
risk  to  the  mother's  life  is  always  enhanced  by  an  introduction  of  the 
hand  into  the  uterus;  that  it  is  sometimes  very  difficult,  if  not 
impossible  to  effect  it,  and  that  the  fatality  to  the  child  is  very  great 
where  it  has  been  performed,  about  one  in  three  being  lost. 

The  cases  in  which  turning  may  be  effected  with  advantage,  are  in 
shoulder  presentations;  transverse  presentations  of  the  body;  mal- 
positions of  the  head ;  difficult  breech  labors ;  placenta  pra?via ; 
hemorrhages ;  convulsions ;  prolapse  of  the  cord ;  rupture  of  the 
uterus;  syncope;  and  whenever  the  mother's  life  is  jeopardized.  It 
must  not  be  forgotten,  however,  that  turning  is  never  to  be  attempted 
when  the  head  or  presenting  part  has  passed  through  the  brim  into 
the  pelvic  cavity ;  delivery  must,  in  this  case,  be  effected  by  the 
forceps  or  perforator.  When  the  head  passes  into  the  vagina,  the 
cervix  will  contract  around  the  neck  of  the  child,  and  it  will  then  be 
impossible  to  return  it  into  the  uterus.  But  when  the  head  has  not 
completely  passed  beyond  the  os  uteri  and  the  superior  strait  into  the 
vagina,  it  may  be  pushed  upward  into  the  uterus,  and  version  may 
then  be  accomplished. 

The  most  important  point  for  the  accoucheur  to  determine,  is  the 
suitable  time  for  the  operation;  a  precipitate  interference,  or  too  long 
a  postponement,  are  equally  fraught  with  danger.  There  are,  however, 
instances  in  which  delivery  by  turning  should  be  promptly  effected, 
and  others,  again,  in  which  it  should  be  delayed. 

Turning,  when  required,  should  always  be  accomplished  as  soon  as 
possible,  in  placenta  prsevia,  in  preternatural  presentations,  in  profuse 
hemorrhage,  and  whenever  symptoms  arise  which  threaten  the  life  of 
the  mother  or  child,  provided,  in  each  instance,  the  os  uteri  be  soft, 
dilatable,  and  sufficiently  dilated. 

It  should  be  delayed,  when  the  os  uteri  is  rigid,  or  soft  but  not  suf- 
ficiently dilated,  until  these  conditions,  especially  the  first,  have  been 
overcome  naturally,  or  by  proper  treatment;  and,  when  the  mem- 


URNING-    OR   VERSION PODALJC    VERSION.  577 

branes  have  been  long  ruptured,  the  liquor  amnii  having  entirely 
escaped,  and  the  uterus  contracting  powerfully  upon  the  fetus. 

At  an  early  period  of  labor  it  is  very  difficult  to  detect  a  mal- 
presentation,  or  a  mal-position,  although  it  may  be  suspected  by 
the  shape  of  the  protruding  bag  of  waters,  as  heretofore  mentioned; 
but,  when  the  os  uteri  has  nearly  completed  its  dilatation,  and 
more  especially  when  the  membranes  have  ruptured,  any  preter- 
natural presentation  may  be  correctly  determined.  And  this  period  is 
always  the  most  favorable  for  the  operation  of  the  version.  Should, 
however,  a  mal-presentation,  requiring  turning  before  labor  can  be 
terminated,  be  detected  before  the  membranes  have  ruptured  (as  a 
shoulder  presentation,  or  placenta  prsevia,  etc.),  the  operator  may 
attempt  the  version,  as  soon  as  the  state  of  the  os  uteri  will  permit  the 
introduction  of  the  hand,  without  the  employment  of  force ;  in  this 
case,  as  the  hand  advances,  the  membranes  become  ruptured,  the  wrist 
and  arm  prevent  the  liquor  amnii  from  escaping,  the  uterus  remains 
distended,  and  the  turning  is  readily  accomplished.  But,  although 
prompt  action  of  this  kind  is  required  in  placenta  prsevia,  or  hemor- 
rhage, a  delay,  until  the  os  uteri  is  fully  dilated  and  the  membranes 
ruptured,  does  not  necessarily  occasion  any  greater  risk  in  a  presenta- 
tion of  the  shoulder. 

When  the  os  uteri  is  rigid,  or  when,  the  waters  having  been  long 
discharged,  the  uterus  contracts  powerfully  upon  the  fetus,  no  attempts 
at  introducing  the  hand  must  be  made  until  the  rigidity  has  been 
overcome,  or  the  irritable  condition  of  the  uterus  lessened  by  the  means 
heretofore  named. 

Turning  has  been  advised  as  a  substitute  for  the  employment  of  the 
perforator,  in  some  cases  of  narrow  or  deformed  pelvis ;  but,  from  the 
difficulty  in  always  being  able  to  correctly  ascertain  the  relative  pro- 
portions between  the  fetal  head  in  utero  and  the  pelvic  diameters,  it 
seems  to  me  an  infeasible  plan.  The  risks  to  the  mother  must  be 
greatly  augmented  by  the  operation  if  unsuccessful,  while  those  to  the 
child  will  be  by  no  means  diminished.  And  yet  cases  are  recorded  in 
which  the  operation  has  proved  a  success.  The  reason  given  for  this 
practice  in  pelvic  deformity  is,  however,  certainly  one  deserving  con- 
sideration, namely :  that  the  bimastoid  diameter  or  base  of  the  fetal 
skull  being  smaller  than  the  bi-parietal  diameter  by  from  half  an  inch 
to  three-quarters  of  an  inch,  it  may  be  drawn  through  the  brim  of  a 
pelvis,  the  antero-posterior  diameter  of  which  is  2J  to  2f  inches ;  and 
that  when  delivery  is  effected  in  this  manner,  the  bi-parietal  diameter 
will  admit  of  compression  that  will  elongate  the  head  and  diminish 
37 


578  KING'S  ECLECTIC  OBSTETRICS. 

this  latter  diameter  so  that  the  passage  of  the  head  may  be  effected. 
While,  on  the  other  hand,  when  the  vertex  presents  at  the  deformed 
brim,  the  contractions  of  the  uterus  cause  it  to  bulge  out  laterally  and 
thus  increase  the  bi-parietal  diameter.  The  operation  is  not  advised 
where  there  is  diminished  transverse  diameter  of  the  brim,  but  only 
where  the  antero-posterior  diameter  is  small,  or  where  there  is  oblique 
deformity.  The  advantages  of  this  practice  are,  that  it  can  be  per- 
formed at  an  early  period  of  the  labor,  and  does  not  subject  the  mother 
to  injuries  from  the  use  of  instruments;  the  disadvantages  are,  as 
stated  above,  and  likewise,  should  it  prove  unsuccessful,  the  woman 
would  have  to  undergo  a  still  further  shock  from  the  employment  of 
the  perforator.  It  is  better  never  to  attempt  this  operation  until  one 
or  more  experienced  consulting  accoucheurs  have  examined  the  deform- 
ity and  the  diameters  of  the  fetal  head,  and  pronounced  it  practicable. 
— whenever  such  consultation  can  be  had  in  time. 

It  may  be  useful  here  to  mention  some  points  made  out  by  Prof.  J. 
Matthews  Duncan,  M.D.,  of  Edinburgh,  concerning  the  tensile  strength 
of  the  fully  developed  fetus,  being  the  result  of  experiments  insti- 
tuted with  the  view  of  determining  this  matter;  according  to  his 
statements,  the  spinal  column  snaps  under  a  weight  of  about  105 
pounds,  while  the  neck,  which  is  the  first  to  give  way.  requires  a  force 
of  120  pounds.  So  far  as  mere  strength  of  materials  is  concerned, 
traction  upon  one  leg  only  is  sufficient  to  dissever  the  neck.  As  in 
the  neck,  so  in  the  legs,  the  bones  give  way  before  the  soft  parts.  Ifi 
a  contracted  brim,  the  body  being  delivered,  the  accoucheur  should 
never  exert  a  traction-force  over  120  pounds  in  his  efforts  to  draw 
the  head  through  the  brim,  if  he  does,  the  neck  will  give  way.  Al- 
though a  much  greater  extractive  force  can  be  used  when  the  forceps 
are  applied, — in  podalic  version  it  should  never  exceed  1 20  pounds'. 

The  mode  of  performing  podalic  version  has  already  been  de- 
scribed; the  principle  of  the  operation  is  about  the  same  in  all  cases. 
I  will,  therefore,  at  this  place,  merely  recapitulate.  Empty  the 
bladder  and  rectum,  the  first  more  especially ;  place  the  female  on 
her  back,  with  the  hips  brought  a  little  over  the  edge  of  the  bed,  her 
legs  flexed  back  and  properly  supported.  Protect  the  floor  from 
the  discharges.  Select  that  hand  for  the  operation,  whose  palmar 
surface  corresponds  to  the  anterior  surface  of  the  child's  body.  (If 
an  arm  presents,  secure  it  by  a  ribbon,  in  order  to  prevent  its  rising 
and  interfering  with  the  passage  of  the  head.)  The  hand  and  arm 
must  be  oiled,  and  warmed  in  water  [there  is  no  necessity  for 
oiling  the  palmar  surface  of  the  hand]  and  the  former  carefully  intro- 


TURNING,     OR    VERSION PODALIC    VERSION.  579 

duced,  in  a  conical  form,  within  the  vagina,  during  a  pain  ;  it  must 
be  passed  into  the  uterine  cavity  during  the  absence  of  pain,  while,  at 
the.  same  time,  the  external  hand  must  be  placed  on  the  abdomen,  over 
the  fundus,  to  support  the  uterus;  seize  the  child  by  the  knee  (hook- 
ing the  finger  in  its  flexure),  or  by  the  feet,  being  careful  that  a  foot 
and  not  a  hand  be  grasped,  and  turn  the  child  during  the  absence  of 
pain,  bringing  the  inferior  extremities  downward  and  over  its  front. 
If  the  limbs  be  brought  over  the  back  of  the  child,  the  spine  may, 
probably,  be  dislocated.  The  traction  must  be  gentle  and  con- 
tinuous, and  not  by  jerks  or  forcible  measures.  Be  careful  to  so 
manage  the  operation,  that  at  the  last  stage  of  the  delivery,  the  face 
of  the  child  will  be  in  the  hollow  of  the  sacrum.  When  the  version 
is  finished,  replace  the  female  in  the  bed,  and  leave  the  delivery  to 
nature ;  or,  should  it  be  necessary  to  effect  this  artificially,  wait  for  the 
uterine  contractions  and  act  in  concert  with  them  ;  for  if  the  tractions 
be  continued,  and  the  delivery  completed  without  uterine  action  having 
taken  place,  the  sudden  evacuation  of  the  organ  would  be  apt  to  give 
rise  to  inertia,  hemorrhage,  or  other  difficulties.  While  the  hand  is 
within  the  uterine  cavity,  should  a  pain  come  on,  do  not  present  the 
knuckles  for  the  organ  to  contract  upon  and  run  the  risk  of  rupture, 
but  grasp  the  body  of  the  child  with  the  open  hand,  removing  it  from 
the  child's  body,  only  when  the  pain  has  ceased.  When  the  uterus  acts 
powerfully  and  vigorously,  it  interferes  with  the  introduction  of  the 
hand,  as  well  as  the  detection  of  the  feet,  and  the  version:  and  the 
operation  becomes  not  only  a  difficult  o-ne,  but  painful  to  both  the 
physician  and  patient.  The  operation  is,  however,  comparatively  an 
easy  one,  when  the  uterus  does  not  act  with  much  force. — The  best 
period  for  performing  the  version,  is  when  the  os  uteri  is  fully  dilated, 
or  nearly  so,  is  soft  and  the  membranes  are  entire;  if  they  have  rup- 
tured, the  os  being  soft  and  dilatable,  the  version  should  be  promptly 
accomplished.  Frequently,  however,  there  will  be  no  choice,  and  we 
may  be  obliged  to  operate  under  very  disadvantageous  circumstances. 
Sometimes,  it  will  only  be  necessary  to  pass  two  or  three  fingers  within 
the  cavity  of  the  uterus,  as  one  or  both  feet  may  be  within  easy  reach. 
Dr.  Barnes,  the  eminent  English  gynecologist,  has  given  the  following 
rules:  "In  all  dorso-anterior  positions  (the  back  of  the  child  looking 
to  the  abdomen  of  the  mother),  lay  the  patient  on  her  left  side ;  pass 
your  left  hand  into  the  uterus — it  will  pass  most  easily  along  the  curve 
of  the  sacrum  and  the  child's  abdomen ;  your  right  hand  is  passed 
between  the  mother's  thigh,  to  support  the  uterus  externally.  In  the 
ease  of  abdomino-anterior  positions  (the  abdomen  of  the  child  look- 


580  KING'S  ECLECTIC  OBSTETRICS. 

ing  to  the  maternal  abdomen),  lay  the  patient  on  her  back,  and  you- 
may  introduce  your  right  hand,  using  the  left  hand  to  support  the 
uterus  externally." 

The  hazards  to  which  the  mother  is  exposed  in  the  accomplishment 
of  version,  are,  1st,  A  rupture  of  the  vagina,  through  which  the  fingers 
or  hand  of  the  operator  may  pass,  and  which  may  be  occasioned  by 
the  employment  of  too  much  force,  omitting  to  support  the  fundus 
externally,  or,  a  neglect  in  passing  the  hand  in  the  direction  of  the 
pelvic  axes.  2d,  If  the  search  for  the  feet  be  conducted  rudely  or 
forcibly,  the  hand  may  be  driven  through  the  uterine  walls.  3d,  The 
hand  of  the  operator,  or  the  limbs  of  the  child  may  so  bruise  or  injure 
the  uterus  as  to  occasion  subsequent  inflammation  ;  but  this  may  arise 
independent  of  such  injury.  4th,  The  shock  to  the  nervous  system  is 
usually  more  serious  than  in  natural  labors  of  the  vertex  or  breech. 

The  child  may  be  destroyed  by  compression  of  the  cord;  or  its  hip, 
or  spine  may  be  dislocated  by  forcible  traction,  or  perhaps  a  limb  may 
be  actually  torn  from  it.  It  must  be  recollected,  that  the  cord  com- 
mences being  compressed  at  the  period  when  the  nates  emerge  from 
the  vulva;  hence,  the  greater  the  delay  in  the  delivery  after  this  time, 
the  more  dangerous  is  it  for  the  child — artificial  respiration  may  be 
attempted,  even  while  the  head  is  in  the  vagina. 

Some  writers  recommend  us  to  seize  the  hips  and  bring  them  to  the 
pelvic  brim,  but  this  is  difficult  and  seldom  attempted ;  others  advise, 
instead  of  searching  for  the  feet  to  bring  down  the  knees  when  these 
are  readily  obtained;  for  the  purpose  of  turning,  I  can  see  no  objection 
to  this  plan.*  As  stated  on  a  preceding  page,  it  is  recommended  to 
turn  by  one  foot,  or  knee,  instead  of  two,  more  especially  on  account 
of  the  increased  dilatation  of  the  soft  parts,  which  must  follow,  and 
thus  afford  greater  facility  for  the  expulsion  of  the  head.  Generally, 

*  Dr.  GueVioit  believes  it  to  be  useless  to  seize  both  feet  in  podalic  version, — one 
alone  will  suffice.  But  we  may  fail  to  get  the  foot,  and  we  may  then  introduce  a  finger 
into  the  rectum.  The  finger  is  hooked  in  a  manner  upon  the  point  of  the  sacrum, 
which  serves  as  a  point  of  support  fully  sufficient  for  giving  the  proper  movements  to 
the  child.  It  may  readily  be  conceived  how  much  more  easy  this  process  is  than  the 
search  for  the  foot,  as  it  requires  only  a  finger  instead  of  the  whole  hand.  With  the 
hand,  the  foot  slips,  and  is  held  with  difficulty; — the  finger  in  the  rectum  has  a  solid 
hold,  and  permits  the  operation  to  be  rapidly  finished. — For  a  dead  child,  this  process 
should  be  resorted  to  at  once ;  for  a  living  one  Dr.  G.  would  hesitate  to  employ  it  lesl 
there  should  result  a  temporary  relaxation  of  the  sphincter,  a  paralysis  of  the  anus,  and 
an  incontinence  of  the  stools  for  some  time.  But  if  very  great  difficulties  are  presented 
to  version  by  the  feet,  he  would  overlook  these  considerations  and  act  at  once  according 
to  the  process. — Jour,  de  Med.  et  de  Chir.  Prat. 


PODALIC   VERSION — THE   FILLET.  581 

this  will  be  found  to  answer.  According  to  actual  measurements,  the 
circumference  of  the  presenting  porti6n  of  the  head,  in  labor,  is  from 
12  to  13-j  inches;  that  of  the  breech,  writh  both  thighs  flexed  upon  the 
abdomen,  is  from  12  to  13J  inches;  that  of  the  breech,  with  only  one 
thigh  flexed,  the  other  being  brought  down,  is  from  11  to  12J  inches; 
and  that  of  the  hips,  both  legs  being  brought  down,  is  from  10  to  llj 
inches.  So  that  it  is  much  safer  for-the  child,  to  accomplish  version 
by  one  foot  or  knee  only.  I  was  called,  some  time  since,  to  a  case 
where  a  foot  and  arm  protruded  beyond  the  vulva,  and  no  justifiable 
degree  of  traction  could  move  the  child,  neither  was  it  possible  to 
return  the  arm.  The  waters  had  been  discharged  at  an  early  period  of 
the  labor,  the  uterus  acted  energetically,  and  the  accoucheur  had  not 
been  able  to  find  the  other  foot.  Finally,  after  some  attempts  at 
changing  the  position  of  the  fetus  in  utero  had  been  made,  he  was 
enabled  to  pass  his  hand  upward,  when  he  found  the  leg  across  and  at 
right  angles  with  the  presenting  one ;  he  carefully  brought  it  down, 
and  the  child  was  delivered  in  a  few  minutes.  In  this  case  it  would 
have  been  impossible  to  have  effected  the  version  by  the  one  foot. 

After  the  delivery,  dq  not  place  the  child  too  soon  to  the  breast, 
but  allow  the  mother  a  rest  for  some  hours;  pursue  the  means  here- 
tofore named,  and  be  prompt  to  combat  the  first  manifestations  of 
inflammatory  action 

It  may  be  proper  to  observe  here,  that  when  turning  is  attempted 
in  vertex  presentations,  the  same  rules  as  laid  down  heretofore,  are 
applicable ;  but  the  head  will  require  to  be  elevated  some  or  moved, 
so  that  it  will  be  placed  in  one  or  other  iliac  fossa. 

The  FILLET,  is  a  strong  piece  of  linen  or  ribbon,  about  three 
inches  in  width,  and  twenty-five  or  thirty  inches  in  length,  and  has 
been  recommended  in  breech  labors,  when  the  pains  are  not  sufficient 
to  complete  the  delivery.  Its  mode  of  application  is  to  oil  or  grease 
it,  and  then,  having  rolled  up  some  five  or  six  inches  of  one  end,  pass 
it  into  the  vagina,  and  by  means  of  the  fingers  push  it  between  the 
child's  thigh  and  abdomen  from  one  side  to  the  other;  then  bring 
down  the  rolled-up  end,  as  it  passes  from  the  side  opposite  to  that  at 
which  it  was  first  carried,  and  tie  the  two  ends  together.  By  this 
means,  the  fillet  is  secured  across  the  thighs,  so  that  traction  may  be 
made  upon  them,  and  which  must  always  be  done  during  a  pain,  acting 
in  concert  with  uterine  action,  or  the  bearing-  down  efforts  of  the 
patient.  It  is  very  difficult  to  adjust  the  fillet,  and,  probably  its  use 
may  be  dispensed  with  altogether.  A  finger,  or  the  blunt  hook,  passed 


582 


KING'S    ECLECTIC    OBSTETRICS. 


FIG.  65. 


between  the  hips  and  abdomen,  may,  with  a  prudent  force,  perform 
all  that  can  be  expected  from  thv  ribbon.  It  is  used,  also,  to  secure 
the  presenting  hand  in  a  shoulder  presentation,  when  turning  is  at- 
tempted, and  thus  prevent  it  from  rising  and  embarrassing  the  deliv- 
er)' of  the  head.  It  should  be  applied  to  the  wrist. 

Whalebone  and  steel  fillets  have  also  been  invented  for  passing  over 
the  head  to  aid  in  its  delivery  when  this  is  required,  as  substitutes  for 
FIG.  66.        the    vectis    and    forceps    in    certain 
cases.    The  best  are  stated  to  be  Dr. 
AVestmacitt's  and  Dr.  Sheraton'.-:    I 
have  never  had   occasion  for  them, 
considering  them  to  be  unscientific, 
and  vastly  inferior  to  the  forceps. 
FIG.  64. 

The  VECTIS,  LEVER,  or 
TRACTOR,  is  an  instrument  some- 
what resembling  one  blade  of  the 
obstetric  forceps.  It  consists  of  a 
steel  blade  fitted  into  a  roughened 
handle  of  hard  wood,  the  whole  in- 
strument being  twelve  or  thirteen 
inches  in  length.  The  extremity  of 
the  blade  is  expanded  like  a  forceps 
blade,  is  furnished  with  a  fenestra, 
and  one  side  is  so  curved  as  to  adapt 
it  to  the  convexity  of  the  head  of  the 
child.  Sometimes  it  is  made  with  a 
hinge,  for  the  purpose  of  carrying  in 
the  pocket,  and  again  it  is  made 
without  a  hinge,  but  having  the 
handle  to  screw  on  the  blade ;  both 

•  *       • 

VECTIS.      BLUNT  HOOK. 

able.     It 

into  a  minute  description  of  the  instrument,  from  the  fact  that  very 
few  obstetricians  of  the  present  day  make  use  of  it;  in  former  times, 
however,  it  was  much  in  vogue.  (Fiy.  64.) 

The  vectis  has  been  recommended  for  the  purpose  of  correcting 
mal-positions  of  the  head,  or  of  aiding  its  movements,  whether  at  the 
brim  or  in  the  pelvic  cavity;  it  has  also  been  advised  as  a  tractor  to 
aid  in  the  delivery  of  the  head.  The  rules  for  its  introduction  are 


BLUNT  HOOK     of  these  latter  forms  are  objection- 

AND  CROTCHET.       i  i          TJ.    • 

is   not   necessary  to  enter 


THE    VECTI.S LEVER    OR    TRACTOR.  583 

somewhat  similar  to  those  for  the  forceps.  The  instrument  should  not 
be  applied  unless  the  os  uteri  is  dilated  and  yielding,  as  also  the  soft 
parts,  and  labor-pains  must  likewise  be  present,  or  its  employment 
would  be  attended  with  no  success.  Instead  of  being  secretly  used,  as 
has  been  frequently  the  case,  the  patient  and  her  friends  should  be  ac- 
quainted with  the  necessity  for  interference,  the  same  as  in  the  use  of 
the  forceps,  and  which  must  never  be  attempted  unless  positively  de- 
manded. Then  having  emptied  the  bladder,  and  rectum  also  if  neces- 
sary, place  the  female  on  her  left  side,  or  on  her  back,  as  the  practitioner 
prefers — though  in  the  latter  position  it  will  be  necessary  to  bring  the 
hips  over  the  edge  of  the  bed,  the  same  as  when  the  forceps  are  em- 
ployed. The  operator  will  now  pass  three  or  four  lingers  of  his  left  hand 
as  high  up  as  possible  within  the  vagina,  over  the  head  of  the  child,  to 
serve  as  a  director  for  the  vectis — which,  having  been  properly  warmed 
and  oiled,  is  to  be  carefully  and  slowly  passed  over  the  convexity  of 
the  fetal  head,  until  the  point  is  reached  to  which  the  force  is  to  be 
applied.  Then  withdraw  the  hand  to  about  the  middle  of  the  instru- 
ment, forming  a  fulcrum  with  it  at  that  point;  the  lever  is  then  of  the 
first  kind — the  right  hand  acting  on  the  handle  by  pressing  it  in  a 
direction  opposite  to  the  one  which  it  is  desired  the  head  should  take- 
Sometimes,  it  is  formed  into  a  lever  of  the  third  kind — the  right  hand 
serving  as  the  fulcrum  or  point  of  support,  while  the  left,  at  the  middle 
of  the  lever,  gives  to  it  the  necessary  movements. 

It  is  frequently  the  case  that  the  vectis  will  have  to  be  placed  on 
several  parts  of  the  head  in  succession,  in  order  to  reduce  its  mal- 
position and  aid  in  its  descent,  and  this  may  be  accomplished  by 
carrying  the  instrument  gently  over  the  circumference  of  the  head, 
from  point  to  point,  without  withdrawing  it;  and  should  any  difficulty 
be  present  interfering  with  its  application,  no  force  must  be  employed 
to  overcome  it — if  it  can  not  be  passed  without  rude  measures  withdraw 
the  vectis,  and  and  reintroduce  it.  It  may  also  be  necessary  to  use  it 
alternately  as  a  lever,  and  as  a  tractor.  When  used  as  a  tractor,  both 
hands  are  to  be  employed  in  making  firm,  but  not  violent  traction  in 
the  direction  of  the  axes  of  the  pelvis,  according  to  the  location  of  the 
head,  and  the  efforts  should  be  made  only  during  the  presence  of  a 
pain,  ceasing  during  an  interval,  and  slightly  raising  or  loosening  the 
instrument  from  the  cranium.  The  least  force  sufficient  for  the  purpose 
is  the  best.  When  the  head  is  at  the  brim,  the  vectis  must  be  applied 
over  the  occiput;  when  at  the  inferior  strait,  it  must  be  introduced 
over  the  sides.  The  necessary  changes  may  be  effected  by  only  three 
or  four  efforts,  sometimes  thirty  or  forty  will  be  required. 


KINGS    Kri,K<:TIC    OHSTETHK  s. 


At  the  present  day  those  who  advise  the  vectis,  limit  its  application 
to  cases — where  the  head  can  not  execute  its  motion  of  rotation  in  the 
pelvic  cavity;  in  face  presentations — applying  it  early  in  labor  over 
the  occiput,  making  traction,  while  at  the  same  time  the  chin  is  to  be 
pushed  up  by  the  hand,  for  the  purpose  of  bringing  down  the  vertex ; 
in  presentations  of  the  side  of  the  head — and,  likewise,  in  instances 
where  the  head  does  not  advance,  the  pains  being  strong,  and  where 
there  is  only  room  sufficient  for  one  blade  to  act.  However,  in  nearly 
ail  these  cases,  the  forceps,  or  a  manual  operation,  will  usually  be  found 
sufficient,  and,  should  the  vectis  be  required,  one  of  the  forcep  blades 
will  be  found  fully  adequate  to  effect  all  that  can  be  accomplished  by 
it.  I  should  hesitate  a  long  time  before  attempting  to  use  this  instru- 
ment on  the  head,  above  the  superior  strait. 

In  the  hands  of  the  unskillful  or  imprudent  operator,  the  vectis  may 
occasion  serious  results;  thus,  if  it  be  introduced  while  the  os  uteri 
is  not  dilatable,  iior  sufficiently  dilated,  it  will  give  rise  to  contusions, 
and  laceration  of  the  parts,  and  death  to  the  mother.  If  it  be  rudely 
or  carelessly  introduced,  the  vagina  or  the  uterus  may  be  ruptured.  If 
the  traction  be  not  made  in  the  direction  of  the  axes  of  the  pelvis,  as 
the  situation  of  the  head  may  require,  not  only  will  the  female  be 
seriously  injured,  but  the  operation  will  prove  of  no  avail.  If  a 
portion  of  the  uterus  be  engaged  in  the  cavity  of  the  blade,  between 
it  and  the  fetal  head,  a  fatal  injury  may  be  the  result.  If  the  traction 
be  made  regardless  of  the  pains,  not  only  will  the  operation  prove 
useless,  but  the  female  will  be  exposed  to  much  danger.  If  the 
instrument  be  pressed  upon  the  soft  parts  of  the  mother,  they  must 
suffer  more  or  less  from  contusion.  If  too  much  force  is  applied  as 
the  head  glides  over  the  perineum,  or  if  this  be  not  supported  at  the 
time,  a  very  serious  rupture  may  be  the  consequence.  Too  much 
pressure  with  the  point  of  the  instrument  upon  the  child,  may  occasion 
a  troublesome  wound. 

Dr.  A.  K.  Gardner's  tractor  is  undoubtedly  a  most  excellent  instru- 
ment for  the  purposes  for  which  it  was  designed,  as  it  does  not  exert 
any  injurious  pressure  upon  the  hard  or  soft  parts  of  the  mother  when 
properly  employed.  It  may  be  used  to  flex  the  head  in  early  departure 
of  the  chin  from  the  breast,  to  aid  in  rotation  in  face  presentations, 
and  for  delivering  the  head  when  necessary,  after  the  birth  of  the  body 
of  the  child.  In  some  cases  it  is  preferable  to  the  forceps,  as  but  one 
blade  is  to  be  applied  (a  saving  of  time),  and  which  has  nearly  the 
same  power  as  the  forceps.  It  is  applied  similar  to  a  forcep's  blade. 


THE    OBSTETRICAL    FORCEPS.  585 

The  BLUNT  HOOK  (Fig.  65)  consists  of  a  round  rod  of  metal,  curved 
at  one  extremity,  and  having  the  other  fastened  into  a  roughened 
handle  of  hard  wood.  Hodge's  forceps  (Fig.  68)  are  so  arranged  that 
either  blade  may  be  employed  as  a  blunt  hook ;  it  may  likewise  be 
obtained  in  one  rod  without  any  handle,  the  extremity  opposite  to  the 
blunt  hook  being  formed  into  a  crotchet.  It  is  used  in  presentations 
of  the  breech,  when  delay  in  the  labor  renders  it  necessary  to  makf. 
traction,  and  the  finger  can  not  be  introduced  into  the  groin,  or  wheii 
the  finger  can  not  exert  a  sufficient  degree  of  traction  :  it  may  also  be 
used  in  those  cases  where  it  becomes  necessary  to  pull  down  the  feet, 
but  which  it  is  impossible  to  effect  by  the  fingers.  It  is  also  occasion- 
ally employed  in  those  cases  where,  the  head  having  been  delivered, 
the  thorax,  from  its  size,  prevents  any  further  advance  of  the  labor; 
in  these  instances,  it  is  passed  into  the  axilla  of  the  shoulder  nearest 
the  sacrum,  to  disengage  this  first.  It  has  also  been  recommended  aa 
a  substitute  for  the  crochet,  when  the  cranial  bones  are  so  loose  as  to 
render  it  almost  impossible  to  obtain  a  purchase  upon  them  by  the 
crotchet :  the  blunt  hook  may  in  these  cases  be  passed  behind  an 
orbit,  or  into  the  foramen  magnum. 

This  instrument  is  to  be  applied  in  a  manner  similar  to  that  recom- 
mended for  one  blade  of  the  forceps:  it  should  be  passed  with  its  point 
directed  toward  the  palmar  surface  of  the  hand  by  which  it  i«  guided, 
and  when  it  has  reached  the  point  on  which  AVC  design  to  have  it  act, 
give  to  it  a  rotatory  motion  in  the  direction  of  its  axis,  and  thus  cause  its 
free  extremity  to  pass  into  the  axilla  or  fold  of  the  groin,  being  care- 
ful, in  the  latter  instance,  not  to  injure  the  genital  organs  of  the  child. 
After  the  blunt  hook  is  applied,  always  examine  and  ascertain  that  it 
has  been  properly  adjusted,  and  is  in  a  position  to  effect  no  injury  to 
either  the  mother  or  child. 

When  the  groin  can  not  be  hooked  by  passing  the  instrument  in 
front  of  the  anterior  hip,  this  may  be  effected  by  introducing  it  be- 
tween the  thighs.  An  improper  use  of  the  blunt  hook  may  give  rise 
to  serious  difficulties.  It  is  not  very  frequently  employed  at  this  day. 


586  K  I  Mi's    ECLECTIC    OBSTETRICS. 


CHATTEB   XLIII. 

THE     FORCEPS DAVls'     FORCEPS — HODGF/S     FORCEPS  —  (ASKS     IN 

WHICH    TO    BE    USED CASES    IX     WHICH     NOT    TO    BE 

USED PERIOD    FOR    USING    THEM. 

FORMERLY,  when  there  was  any  delay  in  the  advance  of  the  pre- 
senting part  of  the  child,  from  whatever  cause,  it  was  the  custom  to 
insert  a  hook  into  the  eye  or  some  other  part  of  the  child's  head,  and 
then  apply  extracting  force ;  consequently,  but  few  children  were 
saved,  and  those  who  did  live  subsequently,  were  more  or  less  di>li^- 
ured  or  mutilated.  Such  an  operation  must  have  been  repugnant  to 
every  feeling  and  conscientious  man,  causing  him  to  postpone  its  per- 
formance as  long  as  possible,  and  which  delay  would  necessarily  add 
to  the  hazards  of  the  mother. 

But  the  invention  of  the  forceps  has  relieved  the  obstetrician  in  a 
great  measure  of  these  unpleasant  operations,  while  at  the  same  time 
it  has  been,  and  still  continues  the  means  of  saving  the  lives  of  numer- 
ous children,  as  well  as  mothers.  The  forceps  were  invented  in  the 
sixteenth  century,  prior  to  1647,  by  Dr.  Peter  Chamberlen,  who, 
together  Vith  his  sons,  kept  it  secret  until  some  time  in  the.  early  part 
of  the  seventeenth  century j  when  it  became  gradually  known  to  the 
profession.  However,  it  had  been  employed  by  Solinger  in  Germany, 
and  Palfyn  in  France,  for  some  time  before  it  became  generally  known 
what  the  instrument  was,  or  who  was  its  inventor.  Since  its  intro- 
duction the  original  instrument  has  undergone  various  modifications, 
some  of  which  are  less  objectionable  than  others,  or,  perhaps,  are 
superior  only  in  certain  cases.  It  is  unnecessary  to  •  enter  into  a 
detailed  history  of  the  invention  and  introduction  of  the  instrument, 
or  to  describe  the  many  changes  through  which  it  has  passed ;  for  such 
information,  there  are  various  works  to  be  readily  obtained,  which 
contain  all  the  particulars,  and  which  those  who  are  curious  in  thiei 
matter  may  consult.  The  limits  of  this  work  will  not  permit  more 
than  a  close  adherence  to  the  practical  and  useful. 

The  obstetrical  forceps  is  composed  of  two  arms  or  branches,  each 
of  which  has  three  distinguishing  parts  :  1st,  the  cochlea,  blade,  jaw, 
or  clamp,  which  is  shaped  somewhat  like  the  bowl  of  a  spoon,  and  the 
concavity  of  which  is  intended  to  be  applied  on  one  side  of  the  child's 
head ;  2cl,  the  junctura,  joint,  lock,  or  hinge,  at  which  point  the  two* 


*  THE    OBSTETRICAL    FORCEPS.  587 

blades  articulate  with  each  other  ;  and  3d,  the  manubrium,  or  handle — 
which  should  be  of  sufficient  length  to  enable  the  accoucheur  to  operate 
with  facility.  The  blade  of  each  branch  has  an  opening  or  fenestrum, 
which  lessens  its  weight  materially,  beside  having  the  advantage  of 
allowing  the  parietal  protuberance  to  pass  out  beyond  them,  when 
applied  over  the  sides  of  the  headland  thus  lessening  the  diameter 
which  would  be  presented,  were  the  blades  solid ;  each  blade  is 
curved  in  the  direction  of  its  longitudinal  axis,  as  well  as  in  that  of 
its  transverse,  which  enables  the  instrument  to  be  more  readily  intro- 
duced and  acted  upon  in  the  direction  of  the  pelvic  axis.  The  joint 
in  each  blade  varies,  one  being  furnished  with  a  pivot  and  the  other 
with  a  notch  or  mortise ;  when  the  two  are  properly  united,  the  blades 
are  firmly  locked.  Others  are  made  with  the  double  mortise  joint; 
the  blades  firmly  locking  without  a  pivot,  making  it  less  difficult  to 
adjust  them.  To  distinguish  the  blades  from  each  other,  the  one 
with  the  pivot  is  termed  the  male  blade,  and  that  with  the  mortise  the 
female  blade.  The  handles  of  the  Hodge  forceps  are  similar  in  each, 
having  a  curvature  externally,  which  not  only  admits  of  their  being 
firmly  grasped  without  slipping,  but  also  serves  to  fulfill  all  the  pur- 
poses of  a  blunt  hook.  In  other  varieties  the  handles  are  shorter, 
not  curved,  and  usually  mounted  with  wood. 

There  are  two  descriptions  of  forceps  in  general  use,  the  short  and 
the  long;  the  former  were  more  in  vogue  some  years  ago,  but  since  the 
excellent  improvements  made  in  the  long  forceps  by  Prof.  Hodge,  it 
is  more  in  favor — because,  while  it  possesses  all  the  benefits  of  the 
short  forceps,  it  has  an  advantage  in  its  applicability  to  operations  at 
the  brim,  when  these  are  required.  The  short  forceps  are  only  useful 
when  the  head  is  at  or  near  the  inferior  strait. 

Nearly  every  obstetrician  has  some  favorite  model  of  this  instru- 
ment; but  among  the  short  forceps,  I  believe  those  of  Prof.  Davis, 
of  London,  have  been  more  generally  preferred  by  the  profession  of 
this  country.  Prof.  Meigs,  who  adopted  them,  gives  the  following 
description  :  "  It  weighs  ten  ounces  and  three-quarters,  and  is  in  length 
twelve  inches ;  its  lock  is  the  English  lock,  composed  of  a  notch  in 
the  upper  surface  of  the  left  and  in  the  lower  surface  of  the  right- 
hand  branch.  When  the  handles  are  closed,  the  ends  of  the  clamps 
are  seven-tenths  of  an  inch  apart,  while  the  fenestrse,  at  their  widest 
part,  are  two  and  three  quarter  inches  asunder.  The  broadest  part 
of  the  fenestrum  is  equal  to  two  inches,  while  its  whole  length  is  five 
inches.  From  the  extremities  of  the  handles  to  the  lock  or  point 
where  the  branches  cross,  is  four  and  a  quarter  inches.  After  the 


588  KIN<;'s    KCLKCTIC    OBSTKTHJ*  s. 

branches  are  crossed,  they  do  not  divaricate,  but  proceed  in  parallel 
lines  one  inch  and  a  quarter;  hence,  if  a  fetal  head  be  ever  so  con- 
siderably elongated  by  the  pressure  of  the  parts,  the  clamps  are  suffi- 
ciently capacious  to  contain  it,  being  seven  inches  long.  In  this  in- 
strument, such  are  the  width  and  length  of  the  fenestrse,  that  a  large 
part  of  the  parietal  protuberances  jut  out  through  or  beyond  them 
when  they  are  fixed  on  the  head."  *  "Its  interior  face 

is  perfectly  adapted  to  the  rotundity  of  those  parts  of  the  head  which 
it  touches;  while  the  fenestrse  are  so  vast  as  to  permit  considerable 
portions  of  the  parietal  protuberances  to  project  as  segments  of  curves 

outside  and  beyond  the 
fenestral  openings.  It 
would  be  true  to  say  that 
the  instrument,  when  ac- 
curately adjusted  upon  the 

sides     of    the     cranium, 
HALE'S  SHORT  OBSTETRICAL  FORCEPS.  i  i_       j.i 

scarcely  touches  the  mater- 
nal tissues  within  the  pelvis.  The  exterior  curves  are  also  arranged 
so  accurately  that  the  tissues  of  the  mother  can  never  touch  the  edges 
of  them;  so  that  they  can  not  be  cut  by  them,  the  surfaces  of  contact 
being  everywhere  broad  and  gently  rounded.  The  admirable  form 
of  the  old-curve,  or  head-curve,  enables  the  instrument  to  touch  very 
large  portions  of  the  cranial  surfaces,  pressing  them  equally,  and  not 
unequally;  so  much  so,  indeed,  that,  when  the  instrument  is  ac- 
curately applied,  it  would  be  a  very  difficult  matter  to  do  with  it  the 
least  injury  to  the  fetus,  since  it  can  scarcely  slide." 

The  short  forceps  designed  by  Prof.  Hale  answers  a  very  good 
purpose  also,  and  is  preferred  by  many  physicians.  (Fig.  67.) 

But,  however  useful  the  above  forceps  may  be,  it  is  a  matter  of  con- 
siderable moment  to  so  simplify  all  our  instruments,  that  one  only  of 
them  may  be  adapted  to  the  accomplishment  of  several  purposes;  and 
this  is  more  especially  necessary  in  obstetrics,  in  which  it  frequently 
occurs  that  delay,  even  of  a  short  interval,  is  attended  with  serious 
results.  On  this  account  Hodge's  improved  long  forceps  have  been 
more  usually  preferred  by  many  than  others,  not  only  because  of  their 
lightness  and  correct  form  and  adaptation  to  the  purposes  for  which 
they  are  intended,  but  likewise  because  they  combine  the  utility  of  the 
short  forceps,  the  long  forceps,  the  vectis,  and  the  blunt  hook.  This 
instrument  is  a  modification  of  the  long  French  forceps,  and  is  de- 
scribed by  Prof.  Hodge  himself,  as  follows: 


HODGE'S   FORCEPS.  589 

"  The  great  object  of  the  forceps  is  to  extract  the  head  of  the  fetus 
from  the  mother's  organs,  in  suitable  cases,  without  injury  to  the 
mother  or  child.  It  is  notorious  that  injuries  to  one  or  both  parties 
frequently  result,  exciting  a  too-well  founded  dread  of  this  instrument 
in  the  minds  of  females,  and  even  of  physicians.  Many  causes  con- 
tribute to  this  unfortunate  result.  No  doubt  much  depends  on  the 
size,  weight,  and  especially  on  the  form  of  the  instrument  employed, 
a  fact  confirmed  by  the  almost  innumerable  varieties  which  have  been 
suggested.  The  instrument,  as  heretofore  used,  is  evidently  imperfect; 
and  the  one  now  suggested,  is  presented  under  the  impression  that, 
while  it  maintains  all  the  excellencies  of  the  former  varieties,  the 
injurious  influences  are  partly,  if  not  wholly,  avoided.  It  is  a  modifi- 
cation of  the  long  French  forceps,  but  may  be  well  termed  an  eclectic 
forceps,  as  combining,  as  much  as  possible,  the  peculiar  excellencies 
of  the  English,  German,  and  French  varieties. 

"  The  advantages  of  the  French  or  long  forceps  are,  I  think,  many 
and  decided,  as,  1st,  by  them,  any  operation  pertaining  to  this  instru- 
ment, can  be  performed.  There  is  no  necessity  to  vary  the  form, 
structure,  or  size,  of  the  instrument,  whatever  may  be  the  presentation 
of  the  head,  its  position,  or  its  location.  2d.  By  them,  sufficient 
power  can  be  applied  in  cases  of  necessity,  which  can  not  be  done  by 
the  short  forceps.  Their  leverage  is  greater.  3d.  The  narrowness  of 
the  blades,  which,  without  detracting  from  the  utility  of  the  instru- 
ment, will  allow  of  their  application  to  the  sides  of  the  head,  even  in 
oblique  and  transverse  positions.  Many  of  the  modern  English  forceps 
are  too  broad  to  allow  the  proper  manipulation  of  the  instrument  in 
the  cavity  of  the  pelvis.  They  can  not  be  introduced  through  the 
vulva  without  pain,  especially  in  first  labors.  The  French  forceps 
can  very  generally  be  applied  without  pain. 

"4th.  It  may  be  added  as  another  advantage,  that  as  habit  in  the 
use  of  an  instrument  is  all-important,  the  practitioner  will  sooner 
become  accustomed  to  a  forceps  which  he  can  employ  on  all  occasions, 
than  when  he  is  obliged,  to  vary  it  continually;  especially  when  it  is 
remembered  that  among  the  strong  and  well-formed  females  of 
America,  cases  for  the  forceps  are  not  very  numerous  in  the  circle  of 
any  practitioner. 

"  The  disadvantages,  which  experience  has  taught  me  arise  from  the 
French  forceps  are : 

"  1st.  Its  unnecessary  weight. 

"  2d.  The  pelvic  curve,  in  the  variety  most  in  use  in  this  country, 
is  not  sufficiently  great.  Hence,  when  the  head  is  high  in  the  pelvis, 


590  KINO'S  ECLECTIC  OBSTETRICS. 

the  perineum  will  be  too  much  pressed  upon,  or  else  the  blndes  will  be 
applied  in  the  direction  of  the  occipi to-frontal  or  longitudinal  diameter, 
instead  of  the  occipito-mental  or  oblique  diameter. 

"  3d.  The  divergence  of  the  blades  commencing  at  the  joint  must 
necessarily  distend  the  vulva  (especially  its  posterior  margin)  prema- 
turely, and  when  the  head  is  high  up,  gives  pain  and  endangers  the 
laceration  of  the  perineum. 

"4th.  The  small  size  and  kite-like  shape  of  the  fenestra  prevents 
any  portion  of  the  cranium,  even  of  the  parietal  protuberances  pro- 
jecting into  their  openings:  hence,  the  hold  on  the  head  is  less  firm, 
and  space  is  occupied  by  the  blades,  the  thickness  of  which  is  added 
to  the  transverse  diameter  of  the  head. 

"5th.  The  flatness  of  the  internal  or  cephalic  surfaces  of  the  blades, 
so  that  the  margin  of  the  fenestra,  often  measuring  three-eighths  of 
an  inch,  is  much  thicker  than  the  external  edge  of  the  blade,  increases 
the  space  occupied  by  the  instrument.  Hence,  in  cases  of  difficulty, 
where  compression  is  employed,  contusion  or  even  wounding  of  the 
scalp  results. 

"6th.  The  mode  of  junction  of  the  French  forceps  is  decidedly 
inconvenient  when  compared  with  the  English,  and  especially  with 
the  German  mode. 

"  These  disadvantages  I  have  endeavored  to  obviate  without  dimin- 
ishing or  circumscribing  the  utility  of  this  most  valuable  instrument, 
to  which  the  profession  and  the  public  are  so  much  indebted.  My 
experience  encourages  the  hope,  that  the  attempt  has  been  in  a  very 
great  degree  successful,  so  that  even  in  inexperienced  hands,  the  dangers 
of  the  forceps  have  been  materially  lessened. 

"  1.  The  weight  of  the  instrument  has  been  diminished  from  twenty 
ounces,  avoirdupois,  to  seventeen  ounces. 

"  2.  The  pelvic  curve  has  been  slightly  increased,  so  that  the  peri- 
neum may  not  be  dangerously  pressed  upon  when  the  blades  are  in 
the  axis  of  the  superior  strait.  To  counteract  any  loss  of  power  which 
may  ensue,  from  the  increased  curvature,  there  is  an  angular  bend  in 
the  handles,  in  an  opposite  direction,  that  the  direct  line  of  traction 
may  be  preserved,  a  suggestion  of  our  skillful  and  experienced  instru- 
ment maker,  Mr.  Rorer. 

"  3.  The  shanks  or  commencement  of  the  blades  are  nearly  parallel, 
diverging  no  more  than  is  absolutely  necessary,  until  they  approximate 
the  head  of  the  child,  when  a  more  rapid  curvature,  than  in  the  Levret 
forceps,  occurs. 


HODGE'S  FORCEPS.  591 

"4.  The  proper  blades  of  the  instrument,  from  the  shanks  to  the 
extremities  are  nearly  of  the  same  breadth  throughout,  being  equal  to 
that  of  the  extremity  of  the  French  forceps. 

"  5.  The  advantages  are  a  more  secure  hold  of  the  head,  and 
•especially  allowing  larger  fenestraB,  so  that  the  parietal  protuberances 
may  project  into  the  openings,  and  no  space  occupied  by  the  blades, 
when  properly  applied. 

"  6.  The  cephalic  surface  of  the  blade  is  concave,  so  as  to  be  adapted 
to  the  convexity  of  the  head,  as  suggested  by  Dr.  Davis  in  his  improved 
forceps,  hence  no  edges  touch  the  scalp,  and  there  is  no  wounding  of 
the  tissues,  even  when  great  compression  is  made. 

"  7.  The  very  ingenious  and  scientific  mode  of  locking  the  blades, 
as  in  the  German  or  Siebold's  forceps,  by  means  of  a  conical  pivot, 
and  the  corresponding  oblique  conical  opening  for  its  reception,  is 
adopted,  by  which  all  the  facilities  of  the  English  junction  are  enjoyed, 
and  the  security  and  firmness  of  the  French  joint  are  maintained. 

"The  eclectic  forceps  weighs  one  pound  and  one  ounce,  being  nine 
ounces  lighter  than  the  French  forceps,  as  usually  manufactured  by 
Rorer,  of  this  city,  and  eleven  ounces  lighter  than  a  specimen  of 
Dubois  forceps  in  my  possession,  made  in  Paris. 

"  The  whole  length  of  the  instrument  (Fig.  68)  in  a  direct  line  from 
b  to  c  is  16  inches;  from  the  joint  a  to  the  extremity  6,  the  length  of 
the  handles,  is  6.8 ;  from  a  to  d,  length  of  parallel  shanks,  is  3.5 ; 
from  d  to  c,  the  proper  blades  in  a  direct  line,  is  6  inches;  from  c  c, 
the  extremities,  to  ef,  the  greatest  breadth,  3.7  inches. 

"  The  separation  between  the  points  c  c,  when  the  handles  are  in 
contact,  is  .5  of  an  inch;  from  e  to  /,  the  greatest  breadth  when  the 
handles  touch,  is  2.5;  when  the  separation  at  ef  is  3.5,  the  points  c  c 
are  separated  to  two  inches;  the  breadth  of  the  blade  is  1.8,  slightly 
tapering  to  1.7  near  c  c,  the  extremities.  The  breadth  of  the  fenestra 
is  1.1;  the  thickness  of  the  blade  is  .2  of  an  inch.  The  perpendicular 
elevation  of  the  points  c  c,  when  the  instrument  is  on  a  horizontal 
surface,  is  3.4  inches,  which  indicates  the  degree  of  curvature  of  the 
blades. 

"The  elevation  of  the  handles  near  the  point,  above  the  same 
horizontal  line,  is  1.3  (including  the  thickness  of  the  blades),  which 
indicates  the  extent  of  the  angular  bend  in  the  handles." 

It  is  sometimes  the  case  that  the  head  is  delayed  in  its  descent  in 
consequence  of  its  bi-parietal  being  slightly  larger  than  the  antero- 
posterior  diameter  of  the  superior  or  inferior  strait ;  in  such  instances, 
the  instrument  of  Professor  Hodge  may  be  applied  along  the  sides  of 


592 


KING'S    KCLKCTIC    OBSTETRICS. 


the  head,  and  sufficient  compression  oe  made  upon  this  diameter  to 
insure  its  passage  through  the  brim,  and  into  the  pelvic  cavity,  or 
through  the.  outlet.  Too  much  compression,  however,  will  dcstn>v 
the  child,  and  this  should  always  be  kept  in  mind  when  operating. 

From  experiments  instituted  by  Baudelocqtie,  upon  several  still- 
born children,  as  to  the  amount  of  compression  which  the  fetal  head 
will  safely  bear,  he  found  that  the  degree  of  reduction  which  the 
diameters  may  harmlessly  undergo,  is  very  inconsiderable,  not  exceed- 
ing four  and  a  half  or  five  lines;  that  the  extent  of  the  reduction 


HODGE'S  FOBCEPS. 

depends  much  upon  the  more  or  less  perfect  ossification  of  the  cranial 
bones,  and  the  ratio  of  closure  of  the  sutures  and  fontanelles,  and  that 
it  can  not  be  properly  estimated  from  the  amount  of  force  employed 
in  approximating  the  handles,  nor  from  the  distance  remaining 
between  them  when  thus  approximated  in  delivering  the  head. 

Professor  Meigs  most  emphatically  pronounces  the  forceps  to  be  the 
child's  instrument,  and  not  the  mother's  —  that  it  is  by  no  means  to  be 
viewed  as  a  compressive  instrument,  but  always  as  an  extractor;  a  dec- 
laration which  should  never  be  forgotten  by  the  obstetric  operator. 


USE    OF    FORCEPS. 


593 


However,  it  may  be  proper  to  state  that  there  are  many  accoucheurs 
\vho,  though  recognizing  the  correctness  of  Professor  Meigs'  remarks 
FIG.  G9.  on  this  point,  as  a  general  principle,  yet  consider 

that  there  may  be  some  exceptions,  as  in  moderately 
contracted  pelves,  in  which  a  gradual  compression 
of  the  head  may  effect  delivery,  without  evil  re- 
sults to  either  the  child  or  its  mother.  Among 
them  I  may  name  Dr.  Rigby,  who  says:  "The  slow 
and  gradual  pressure  of  the  forceps  thus  exerted  (by 
tying  the  handles  together  and  tightening  them 
after  every  successive  effort),  upon  the  head  of  a 
living  fetus,  will  have  a  very  different  result  to 
that  of  the  experiments  of  Baudelocque  and  others, 
in  attempting  to  compress  the  head  of  a  dead  fetus, 
by  the  application  of  a  sudden  and  powerful  force. " 
So  that,  from  these  remarks,  it  may  be  well  to  con- 
sider the  use  of  the  forceps  as  a  compressor,  above 
the  brim,  either  when  its  diameters  FIG.  70. 
are  slightly  diminished,  or  the  bi- 
parietal  of  the  head  somewhat  aug- 
mented, as  a  mere  exception  to  the 
general  rule  that  the  forceps  are  not 
intended  for  compression.  And  when 
compression  is  made,  the  head  being 
within  the  pelvic  cavity,  it  should 
never  be  in  the  direction  of  the  oc- 
cipito-frontal  diameter,  but  always  in 
that  of  the  bi-parietal,  as  being  less 
likely  to  injure  the  child.  Judicious 
management  will  frequently  render  a  resort  to  the  per- 
forator unnecessary. 

In  addition  to  the  forceps  heretofore  named,  there  are 
many  others  employed  by  the  profession,  each  of  which, 
though  framed  upon  the  same  general  principles,  appears 
to  have  certain  advantages  in  its  favor,  and  which  the 
accoucheur  generally  selects  according  to  his  own  views 
— but  it  is  not  necessary  to  give  more  than  this  brief 
reference  to  them,  especially  as  the  rules  herein  given    EA5n 
for  their  employment  are   equally   adapted   to  all  or  any  of  them. 
As  with  many  other  things,  the  forceps  have  not  only  undergone  real 
38 


ELLIOT'S  FORCEPS. 


594 


KING'S    ECLECTIC    OBSTETRICS. 


or  supposed  improvements,  but  have  likewise  passed  through  what 
may  be  termed  periods  of  fashion,  as  to  short  or  long,  style,  design,  etc. 
An  objection  made  by  some  practitioners  to  the  Hodge  forceps  is 
the  inability  to  grasp  the  metallic  handles  in  the  middle,  and  make 
traction,  without  the  hands  slipping;  to  overcome  this,  some  operators 
either  hook  the  index  finger  over  the  lock,  or  wrap  a  napkin  or  towel 
about  them.  There  are  numerous  other  forceps,  however,  that  differ 
from  the  Hodge  in  the  shape  and  finish  of  the  handles,  FIG.  72. 
being  mounted  with  wood,  and  designed  to  give  a  firm 
FIG.  71.  and  permanent  hand-hold.  Among 

these  may  be  noticed  Elliot's  (Fig. 
69),  Reamy's  (Fig.  70),  Sawyer's 
(Fig.  71),  as  well  as  one  of  my  own 
designing  (Fig.  72). 

Elliot's  forceps  differs  from  the 
Hodge,  not  only  in  the  handles, 
but  is  of  much  greater  width  be- 
tween the  blades,  both  through  the 
point  of  greatest  excavation  as  well 
as  the  tips;  it  is  more  especially  re- 
garded as  an  instrument  of  extrac- 
tion rather  than  of  compression, 
and  was  designed  for  application 
to  the  sides  of  the  pelvis  rather 
than  the  sides  of  the  child's  head. 
Dr.  Sawyer's  forceps  is  also  of  this 
design.  The  forceps  bearing  my 
name  is  of  much  lighter  weight 
SAWYER'S  FORCEPS,  than  the  Elliot,  and  can  be  easier 
locked  than  those  with  the  pivot  joint,  and  I  think  will  be  found  a 
very  satisfactory  instrument. 

In  some  countries  the  forceps  are  employed  much  more  frequently 
than  in  others;  thus,  according  to  Churchill,  in  52,268  cases  of  labor 
occurring  in  British  practice,  the  forceps  were  applied  in  144  cases, 
or  about  1  in  362|.  In  44,736  labors  in  French  practice,  they  were 
used  in  277  cases,  or  about  1  in  162;  and  in  261,224  labors  in  Ger- 
man practice,  they  were  resorted  to  in  1,702  cases,  or  about  1  in  153J. 
The  whole  amounting  to  358,228  cases  of  labor,  in  which  the  instru- 
ment was  applied  2,123  times,  or  about  1  in  168J.  The  results  to  the 
mother  in  British  practice,  was  1  death  in  20J  cases;  to  the  child  1  in 
4J.  In  French  and  German  practice,  1  mother  was  lost  in  13J,  and 


WINTERMUTE'S 
FORCEPS. 


USE   OF    FORCEPS.  595 

about  1  child  in  5.  As  the  result  to  the  mother  has  not  been  named 
in  many  instances,  nor  the  peculiarities  of  each  case  given,  these 
statistics  can  be  considered  as  only  approximative.  In  our  own 
country,  the  statistics  have  been  too  meager  and  limited  to  enable  us 
to  form  any  idea  of  the  comparative  frequency  of  forcep  labors,  or 
their  results.  It  has  been  recently  stated  that  "the  more  frequently 
the  forceps  are  employed,  the  less  is  the  mortality  to  the  mother  and 
child."  I  am  not  prepared  to  either  deny  or  admit  this  statement. 
If,  however,  the  remark  be  true,  I  can  only  account  for  it  from  the 
fact  that,  in  cases  where  the  instrument  is  required,  it  is  used  at  a 
much  earlier  period  than  formerly,  while  the  strength  of  the  patient 
enables  her  the  better  to  sustain  the  shock  of  the  operation,  and 
while  the  soft  parts  are  yet  free  from  any  tendency  to  sloughing  there- 
from ;  and,  perhaps,  likewise  to  a  more  perfect  knowledge  of  the  cir- 
cumstances under  which  they  may  be  efficaciously  employed,  as  well 
as  to  a  more  scientifically  "correct  application  of  them. 

The  cases  in  which  a  resort  to  the  forceps  has  been  advised,  are  the 
following — recollecting,  however,  that  the  short  forceps  are  never  to 
be  used  when  the  head  has  not  passed  the  superior  strait : 

1.  To  effect  delivery  in  cases  where  the  uterine   contractions  are 
weak  and  inefficient,  and  can  not  be  aroused  by  the  ordinary  means. 
Thus,  the  head  may  be  in  the  superior  strait,  not  impacted,  but  mak- 
ing no  advance,  in  consequence  of  the  inefficiency  of  the  pains;  here 
the  long  forceps  have  been  advised,  to  assist  in  accomplishing  the 
descent      Or,  the  head  may  present  at  the  brim,  in  a  mal-position, 
which,  not  being  corrected  by  the  pains,  as  well  as  being  incapable  of 
reduction  by  the  hand,  may  be  rectified  by  the  long  forceps,  provided 
the  os  uteri  be  in  a  proper  condition. 

In  the  use  of  the  long  forceps,  I  would  remark  here,  that  when  em- 
ployed at  the  superior  strait,  the  blades  are  to  be  introduced  in  the 
transverse  diameter  of  this  strait,  so  that  a  blade  will  be  within  each 
ilium;  while  both  the  long  and  short  forceps  are  to  be  introduced 
over  the  sides  of  the  child's  head  when  it  has  entered  the  pelvic 
cavity,  a  blade  being  over  each  ear  —  and  which  rules  must  be  borne 
in  mind  when  the  long  forceps  are  employed  as  a  substitute  for  the 
short  ones. 

2.  To  hasten  delivery  when  dangerous  symptoms  to  the  mother  are 
present,  whether  from  too  prolonged  labor,  hemorrhage,  convulsions, 
exhaustion,  rupture  of  the  uterus  when  the  head  is  within  reach,  or 
from  resistance  of  the  muscles  of  the  perineum. 


596  KING'S  ECLECTIC  OBSTKTIJIC.S. 

3.  To  save  the  child's  life  in  some  face  presentations,  and  in  the 
occipito-posterior  positions  when  the  forehead  is  behind  the  pubic  sym- 
physis.     This,  however,  is  not  necessary  in  all  instances  of  the  above 
character,  as  delivery   frequently   terminates  by   the    natural   efforts, 
though  more  slowly,  and  with  a  greater  amount  of  suffering  than  in 
ordinary  cases. 

4.  To  preserve  the  child  in  prolapsus  of  the  cord,  when  the  pulsa- 
tions grow  weak. 

5.  When  there  is  a  detention  of  the  head  within  the  pelvic  cavity, 
heretofore  referred  to  when  speaking  of  the  compressive  action  of  the 
instrument. 

6.  When  an  extremity  descends  with  the  head,  and  can   not  be 
returned,  the  augmentation  of  the  diameter  within  the  pelvis,  may 
require  a  greater  degree  of  expulsive  force  than  can  be  given  by  the 
natural  powers. 

7.  In  breech  labors,  when  there  is  a  delay  in  the  advance  of  the 
head  ;  the  body  and  extremities  having  been  delivered,  the  child  may 
die,  in  consequence  of  compression  of  the  cord,  unless  it  be  removed 
by  the  forceps.     A  few  minutes,  in  these  instances,  generally  deter- 
mine the  life  or  death  of  the  child. 

The  forceps  are  never  to  be  employed  when  the  os  uteri  is  rigid  and 
undilatable,  or  relaxed  but  not  sufficiently  dilated ;  when  the  peri- 
neum is  unyielding ;  when  the  soft  parts  are  inflamed  and  swollen  : 
when  the  diameters  of  the  pelvic  cavity  are  diminished  by  the  presence 
of  tumors;  in  deformities  of  the  pelvis;  when  the  child  is  dead;  and 
when  the  fetal  head  is  hydrocephalic,  or  firmly  ossified.  Neither  is  it 
to  be  applied  to  the  breech.  And  unless  there  exists  some  urgent 
reasons  for  their  use,  as  hemorrhage,  large  head,  small  pelvis,  convul- 
sions, etc.,  they  are  never  to  be  employed  except  the  pains  are  inefficient. 
Indeed,  the  instrument  should  always  be  considered  the  "  child's 
instrument,"  and  a  substitute  for  absent  or  inefficient  expulsive  force 
of  the  uterus ;  and,  under  no  circumstances  whatever,  is  it  justifiable 
to  employ  them  to  save  trouble,  or  in  any  other  way  accommodate  the 
convenience  of  the  practitioner. 

When  the  uterus  acts  energetically,  the  pulse  not  being  over  one 
hundred  beats  in  a  minute,  the  countenance  natural,  the  spirits  good, 
the  tongue  and  mouth  moist  and  clean,  the  abdomen  and  soft  parts 
free  from  pain  on  being  pressed  or  touched,  and  the  head  makes  the 
slightest  advance,  no  interference  is  required,  notwithstanding  the 
labor  may  have  continued  over  twenty-four  hours. 

If  attempts  be  made  to  introduce  the  forceps  before  the  os  uteri  and 
soft  parts  are  in  a  favorable  condition,  rupture  of  the  uterus,  or  lacer- 


USE    OF    FORCEPS.  597 

ation  of  the  perineum  and  vagina  may  be  the  consequence,  and  which, 
when  occurring,  always  proves  more  or  less  hazardous  to  the  mother. 
Nor  is  it  proper,  when  the  head  is  in  the  pelvic  cavity,  to  carry  the 
forceps  within  the  os  uteri,  until  this  has  so  far  risen  above  the  parietal 
protuberance  that  it  can  not  readily  be  felt. 

When  the  soft  parts  are  swollen  and  inflamed,  a  condition  which 
will  seldom  occur  in  the  hands  of  a  careful  accoucheur,  it  will  be 
inexpedient  to  use  the  forceps,  because  of  the  disposition  to  sloughing 
of  the  parts  under  such  circumstances,  and,  therefore,  the  perforator 
will  be  the  safer  instrument  for  the  mother.  The  same  course  will  be 
pursued  in  diminished  pelvic  diameters  from  tumors,  deformities,  or 
other  causes.  In  these  cases  the  child  must  be  sacrificed  for  the  safety 
of  the  mother — this  is  a  fundamental  principle  of  obstetrics.  Gen- 
erally, in  instances  where  the  perforator  will  be  required,  the  pressure 
will  destroy  the  child,  before  the  symptoms  become  so  threatening  as 
to  induce  a  skillful  obstetrician  to  operate. 

When  the  child  is  known  to  be  dead,  which  may  generally  be  deter- 
mined by  the  stethoscope,  the  perforator  is  advised  in  preference  to 
the  forceps;  and  this  is  likewise  recommended  in  hydrocephalic  or 
ossified  heads,  to  be  used,  even  before  the  child's  death,  if  the  safety 
of  the  mother  requires  it. 

As  the  instrument  is  intended  for  the  head  only,  it  could  not  be 
applied  to  the  breech  with  any  degree  of  safety  or  success,  as  it  would 
be  very  apt  to  tear  or  mangle  the  soft  parts  of  the  breech  and  trunk 
upon  which  it  might  be  exercised.  But  it  may  be  frequently  used 
with  advantage  to  extract  the  head,  after  the  body  of  the  child  has 
been  expelled,  when  any  difficulty  or  delay  occurs  in  its  delivery. 

In  impacted  or  locked  head,  the  perforator  will  generally  be  re- 
quired, on  account  of  the  impossibility  of  moving  the  head  with  the 
forceps;  this  condition  of  the  head  is  usually  connected  with  a  small 
pelvis,  or  a  large,  and  perhaps  ossified  head.  But  in  cases  where 
there  is  a  mere  arrest  of  descent,  from  a  close  fitting  of  the  circum- 
ferences of  the  head  to  those  of  the  pelvis,  the  forceps  may  be  used. 

In  all  cases  where  the  head  is  considerably  larger  than  the  pelvis, 
the  forceps,  as  well  as  a  resort  to  turning  are  improper;  and  either 
the  perforator  or  the  Cesarean  operation  will  be  required.  Yet,  as 
our  means  of  accurately  determining  the  size  either  of  the  head  or  of 
the  pelvis,  are  not  always  absolute,  it  is  never  improper  to  attempt  the 
delivery  by  a  careful  and  gentle  employment  of  the  forceps.  It  will 
frequently  happen  that  when  the  antero-posterior  diameter  of  the  brim 
.has  not  reached  three  inches,  the  forceps  may  be  successfully  used. 


598  KING'S  ECLECTIC  OBSTETRICS. 

The  PERIOD  FOR  OPERATING,  will  depend  entirely  upon 
the  circumstances  attending  each  individual  case.  Previous  to  the 
rupturing  of  the  membranes,  the  employment  of  the  forceps  will  be 
unnecessary;  but  after  their  rupture,  in  ordinary  cases,  we  are  to  "be 
guided  more  by  the  constitutional  symptoms  than  by  a  mere  lapse  of 
time.  There  is  one  exception  to  the  statement  just  made,  and  that  is 
when  the  difficulty  "is  at  the  superior  strait,  and  the  head  can  not 
descend  through  it,  in  this  case,  as  too  great  a  delay  may  give  rise  to 
serious  symptoms,  the  second  stage  may  be  considered  to  have  com- 
menced as  soon  as  the  os  uteri  is  fully  dilatable.  The  rule  governing 
our  action  will  depend  on  the  condition  of  the  patient;  if  the  case  is 
progressing  'naturally,  no  signs  of  exhaustion,  the  pains  increasing, 
with  gradual  advancement  of  the  head,  interference  is  uncalled  for. 
Exhaustion,  or  want  of  advancement  of  the  head,  however,  calls 
for  action.  It  was  formerly  the  rule  not  to  interfere  until  the 
second  stage  of  labor  had  continued  for  twenty-four  hours;  it 
frequently  occurs,  however,  that  symptoms  present  themselves  be- 
fore the  twenty-four  hours  have  expired  which  demand  interference; 
and,  again,  many  females  will  sustain  a  prolonged  and  painful  labor, 
with  more  fortitude,  and  less  prostration  of  the  system,  or  other 
unfavorable  symptoms,  than  others.  We  must,  therefore,  be  governed 
principally  by  the  symptoms,  and  partly  by  the  lapse  of  time,  being 
careful  not  to  delay  too  long,  or  until  the  parts  become  dry  and 
inflamed,  and  the  labia  and  perineum  become  infiltrated  with  serum, 
for  then,  laceration  and  sloughing  will  almost  inevitably  ensue.  If 
the  head  remains  arrested  for  four  hours,  we  are  justified  in  operating 
even  though  no  unfavorable  symptoms  exist,  because  by  so  doing  we 
preserve  the  integrity  of  the  soft  structures. 

In  the  selection  of  the  proper  period  for  operating  with  the  forceps, 
in  connection  with  what  has  already  been  stated,  an  attention  to  certain 
circumstances,  will  materially  assist  us.  Thus — if  the  health  of  the 
female  has  been  impaired,  or  if  she  has  previously  suffered  from  a  long- 
continued  sickness,  the  powers  of  the  system  will  be  less  likely  to 
sustain  her  under  a  lingering  labor,  or  to  terminate  the  delivery,  than 
when  she  has  been  in  the  possession  of  good  health ;  though  we  often 
meet  with  females  laboring  under  consumption,  dropsy,  etc.,  whose 
labors  are  as  vigorous  and  natural  as  those  of  the  most  healthy  and 
robust.  If  the  female  has  previously  given  birth  to  children,  there  is 
a  greater  reason  to  suppose  that  the  present  one  may  also  be  born 
without  aid,  unless  there  exist  a  mal-position  or  abnormality  of  the 
head. 


USE  OF  FORCKPS.  599 

Several  hours  having  elapsed  since  the  commencement  of  the 
second  stage  of  labor,  with  symptoms  of  exhaustion,  together  with 
strong  and  regular  pains  without  advancement  of  the  head,  the 
forceps  will  very  probably  be  required ;  we  should  not  be  too  hasty 
in  their  application,  however,  being  governed,  in  a  great  measure, 
by  the  symptoms  present.  Yet  we  must  remember  that  if  the  head 
remains  stationary,  pressing  upon  the  soft  parts  for  four  hours, 
their  structure  becomes  much  endangered.  But,  "if  the  head  ad- 
vances ever  so  slowly,  the  patient's  pulse  continuing  good,  the 
abdomen  free  from  pain  on  pressure,  and  no  obstruction  to  the 
removal  of  urine,"  the  strength  and  spirits  of  the  patient  being 
also  good,  interference,  as  a  general  rule,  is  not  required,  unless  the 
child  be  dead.  The  mortality  to  the  mother  and  child,  in  cases  where 
this  rule  has  been  applied,  is  less  than  among  those  where  the  forceps 
have  been  resorted  to,  and,  it  must  also  be  borne  in  mind,  that  the 
death  of  the  child  alone  does  not  justify  any  interference,  unless  there 
be  sufficient  cause  aside  from  this  fact. 

The  condition  of  the  patient's  strength,  and  her  capacity  of  endurance 
must  also  be  taken  into  consideration ;  and  we  must  be  careful  not  to 
be  misled  as  to  the  exhaustion  of  the  female.  The  uterus  may  be 
acting  energetically,  and  the  woman  be  walking  about  the  room,  and 
yet  she  will  complain  of  being  exhausted ;  the  practitioner  must  be 
guided  by  other  symptoms  than  merely  such  expressions.  When 
exhaustion  is  present,  the  pulse  will  be  very  quick,  over  one  hundred 
beats  in  a  minute;  below  this  there  is  seldom  any  danger.  The  pains, 
also,  gradually  become  weak,  with  lengthened  intervals,  and  finally 
cease ;  and  accompanying  this  condition  there  will  be  a  greater  or  less 
discharge  from  the  vagina,  of  a  faint,  unpleasant,  but  not  putrid  odor, 
and  of  an  olive  color,  and  which  is,  probably,  the  secretion  from  the 
lining  uterine  membrane,  changed  in  consequence  of  the  long-continued 
and  powerful  .exertions  of  the  organ;  this  may  be  considered  one  of 
the  first  manifestations  of  exhaustion.  The  countenance  of  the  patient 
assumes  an  anxious  appearance,  the  cheeks  become  pale,  sallow,  or 
spotted,  the  eyes  sunken  and  dull,  and  the  tongue  will  be  dry  and 
loaded,  either  with  a  brown  sordes,  or,  if  fever  is  present,  with  a  white 
fur.  The  respiration  is  also  hurried,  and  other  unfavorable  symptoms 
may  appear.  Vomiting  of  a  dark  fluid,  having  the  appearance  of 
coffee-grounds,  is  most  generally  present,  when  exhaustion  has 
advanced;  and  when  a  long  period  has  been  allowed  to  elapse,  a 
shivering»coklness  of  the  extremities,  with  cold,  clammy  perspiration 
on  various  parts  of  the  body,  and  delirium  come  on,  indicative  of  great 


600  KING'S  ECLECTIC  OBSTETRICS. 

local  injury  and  extreme  danger.  But  we  must  not  wait  for  these 
more  severe  symptoms,  before  operating — but  should  promptly  act 
upon  the  first  manifestations  of  exhaustion,  and,  in  cases  of  immediate 
clanger,  even  at  a  still  earlier  period. 

The  condition  of  the  abdomen,  and  of  the  soft  parts,  will  also  indi- 
cate operative  interference.  Thus,  if  there  is  tenderness  of  the 
abdomen  on  pressure,  inflammation  is  to  be  dreaded  ;  and  immediate 
delivery  will  be  the  safest  course  to  pursue,  before  inflammatory  action 
becomes  developed.  If  the  soft  parts,  instead  of  being  cool,  soft,  and 
moist,-  become  dry,  hot,  swollen,  and  painful,  so  that  the  least  touch 
can  scarcely  be  allowed,  it  has  been  advised  by  some  writers  to  deliver 
by  forceps;  but  from  the  tendency  to  sloughing  in  such  cases,  I  do  not 
deem  it  the  best  practice.  Still,  an  attempt  to  subdue  the  tenderness 
and  inflammation  by  the  application  of  fomentations  may  be  under- 
taken in  such  cases;  always,  however,  recollecting,  that  the  danger 
increases  in  proportion  as  the  pressure  is  continued.  To  wait,  how- 
ever, for  the  appearance  of  vomiting  of  dark  fluid,  of  cold  shiverings 
or  sweats,  hurried  breathing,  delirium,  or  swelling  and  inflammation 
of  the  soft  parts,  would  be  extremely  injudicious. 

In  all  these  protracted  cases  of  labor,  great  vigilance  is  required 
that  we  do  not  delay  the  operation  so  long  as  to  endanger  the  life  of 
the  mother;  and  if  there  is  a  chance  for  saving  the  child's  life  without 
any  injury  to  the  mother,  the  delivery  may  be  undertaken  even  before 
those  symptoms  appear  which  indicate  a  failure  of  the  powers  of  the 
system.  There  is  always  a  greater  possibility  of  injury  from  too  long 
a  delay,  than  from  interfering  a  little  too  soon. 

Occasionally,  circumstances  will  exist  which  demand  the  use  of  the 
forceps  for  delivery  before  the  rupture  of  the  membranes ;  in  such 
cases,  if  the  os  uteri  is  in  a  favorable  condition  (and  positively  not 
without),  the  membranes  may  be  artificially  ruptured  and  the  instru- 
ment applied.  Such  instances  are,  fortunately,  very  rare. 

The  principal  dangers  to  which  the  mother  is  exposed  when  the 
forceps  are  used,  are  laceration  of  the  vagina,  or  of  the  perineum,  or 
of  both;  laceration  of  the  cervix;  and  contusion  of  the  soft  parts. 
The  child  may  have  its  head  too  much  compressed;  its  -scalp,  or  ear, 
may  be  bruised  or  torn ;  and  the  pressure  may  induce  paralysis  of  the 
facial  nerve. 

The  principle  of  axis  traction  is  at  present  exciting  considerable 
discussion,  and  has  been  adopted  by  a  number  of  obstetricians  in  the 
use  of  the  forceps.  The  idea  was  suggested  by  Dr.  Tarnief,  and  has 
for  its  object  traction  directly  in  the  axis  of  the  pelvis,  by  means  of 


USE    OF    FORCEPS. 


an  attachment  to  the  ordinary  forceps.  I  quote  the  following  from 
Leishman's  Midwifery,  in  reference  to  this  subject:  "An  attempt  has 
been  made,  by  Professor  Tarnier,  to  modify  the  forceps  so  as  to  pull 
FIG.  73.  more  directly  in  the  axis  of  the  brim,  and 

at  the  same  time  to  protect  the  perineum,  and 
to  avoid  injurious  pressure  in  the  direction 
of  the  pubic  symphysis.  The  instrument, 


in  the  construction 
of  which  great  me- 
chanical ingenuity  is 
displayed,  is  sigmoid 
in  shape,  from  the  ad- 
dition of  a  special 
perineal  curve,"  etc. 

The  instrument  of 
Tarnier  was  too  com- 
plicated for  general 
use;  it,  however,  has 
been  simplified  by  re- 
cent modifications,  to 
the  extent  of  render- 
ing it  a  very  desirable 
instrument  in  many 
cases,  and  has  received 
the  endorse- 
ment of  some 
of  the  fore- 
most wrriters 


PIG.  74. 


REYNOLDS'  ATTACHMENT  FOR 
Axis  TRACTION. 


SlMPSON-T.ARNIER  FORCEPS. 

on  obstetrics.  The  principle  is  clearly  shown  in  the  Simpson-Tarnier 
forceps  (Fig.  73) ;  or  possibly  it  will  be  better  understood  by  referring 
to  the  Reynold's  attachment  (Fig.  74).  This  may  be  used  with  any 
forceps.  After  properly  adjusting  the  forceps,  the  arms,  6,  c,  should 
be  attached  to  the  fenestrse  of  the  forceps,  then  connected  at  e,  after 
which  traction  may  be  made  by  applying  the  proper  amount  of  force 
to  the  handle,  d;  the  handles  of  the  forceps  should,  at  the  same  time, 
be  supported  by  the  disengaged  hand. 


602  KING'S  ECLECTIC  OBSTETRICS. 


CHAPTER    XLIV. 

RULES    FOR    APPLYING    THE    FORCEPS MODE    OF    APPLYING     THE 

FORCE1'>    IX    THE    VARIOUS    POSITIONS    OF    THE    HEAD. 

BEFOEE  stating  the  manner  of  applying  the  forceps,  I  will  briefly 
recapitulate  a  few  of  the  general  principles  referred  to  in  the  previous 
chapter,  and  which  should  be  constantly  kept  in  view  by  the  accoucheur. 

1.  When  the  powers  of  nature  are  sufficient  to  effect  the  delivery, 
interference  is  not  required,  unless  circumstances  occur  which  threaten 
the  life  of  the  mother. 

2.  The  forceps,  acting  as  a  substitute  for  the  natural  efforts,  are  to 
be  employed  as  an  extractor,  and  not  as  a  compressor. 

3.  They  are  never,  under  any  conditions  whatever,  to  be  used,  unless 
the  os  uteri  is  sufficiently  dilated  and  dilatable. 

4.  They  may  be  used  when  a  delay  in  the  delivery  would  endanger 
the  child's  life,  but  never  at  the  expense  of  injury  to  the  mother. 

5.  Under  ordinary  circumstances,  they  should  not  be  applied  until 
the   symptoms  of  exhaustion   commence ;   neither  delaying  too  long 
until  the   more  severe   symptoms   come  on,  nor  operating  too  pre- 
maturely. 

6.  They  must  not  be  used  when  the  soft  parts    are  inflamed  or 
swollen,  on  account  of  the  tendency  to  subsequent  sloughing;  neither 
must  they  be  applied  to  any  part  of  the  child  except  the  head. 

7.  The  lateral   motion   or  oscillating   movement  from   handle  to 
handle   must   not  be   allowed  to  take   too  extensive  a  range ;   and 
remember,  that  the  higher  up  the  forceps  are  passed  within  the  pelvic 
cavity,  the  more  limited  will  be  the  extent  of  these   motions,  and 
greater  attention  will  be  required  not  to  injure  the  maternal  soft  parts. 

8.  Always  avoid  hurrying  the  head  through  the  inferior  strait,  and 
fail  not  to  give  support  to  the  perineum  as  it  becomes  extended  by  the 
advance  of  the  head. 

Previous  to  the  introduction  of  the  forcep-b lades,  the  patient,  as 
well  as  her  friends,  should  be  made  acquainted  with  the  character  of 
the  operation,  and  the  necessity  for  it;  for  it  is  not  to  be  supposed 
that  any  physician  would  attempt  an  operation  of  this  kind  without 
the  consent  of  the  patient  or  her  relatives.  It  may,  likewise,  be  a 
judicious  measure,  in  cases  where  imperative  haste  is  not  required,  to 
show  the  instruments  and  explain  their  method  of  operating— 


RULES  FOR  APPLYING  THE  FORCEPS.  603 

remarking  that,  as  the  hands  can  not  be  applied  to  the  sides  of  the 
head  to  assist  in  its  delivery,  these  are  employed  as  substitutes :  and 
that,  in  the  hands  of  a  careful  operator,  they  will  not  be  apt  to  cause 
injury  to  child  or  mother.  Whenever  it  is  possible  to  procure  the 
presence  of  an  another  accoucheur  with  whom  to  consult  and  share 
the  responsibility,  it  should  be  done,  and  will  be  found  a  very 
judicious  measure. 

Consent  having  been  obtained,  the  bladder  must,  in  every  instance, 
be  evacuated,  either  naturally  or  by  catheter ;  and  if  the  rectum  has 
not  been  recently  emptied,  or  if  there  be  an  accumulation  of  the  feces, 
an  injection  should  be  administered.  But  should  the  injection  fail  to 
clear  out  the  rectum,  and  the  symptoms  demanding  delivery  are 
urgent,  the  practitioner  may  proceed  to  the  application  of  the  forceps, 
having,  however,  been  careful  to  empty  the  bladder. 

The  practitioner,  having  turned  up  his  coat  sleeve  and  shirt  wrist- 
band, and  also  protected  his  dress  from  being  soiled,  by  an  apron  or 
something  to  serve  a  similar  purpose,  will  have  the  female  brought 
to  the  edge  of  the  bed,  lying  upon  her  back,  as  in  the  position  for 
turning,  her  feet  resting  on  two  chairs,  or  flexed  back  to  the 
edge  of  the  bed,  and  separated  sufficiently  from  each  other  to 
permit  him  to  sit  or  stand  between  them,  and  her  limbs  are  to 
be  supported  by  two  assistants  (not  necessarily  professional  friends), 
who  are  to  sit  with  their  backs  toward  each  other.  The  patient's  hips 
should  be  brought  so  far  beyond  the  edge  of  the  bed,  that  no  obstacle 
will  be  offered  to  the  introduction  of  the  forceps,  or  to  the  free  use  of 
them  after  having  been  applied. 

In  order  to  prevent  the  floor  from  being  soiled  by  the  discharges,, 
some  cloths  should  be  placed  upon  it  immediately  under  the  hips  of 
the  woman,  and  that  part  of  the  bed  on  which  the  inferior  portion 
of  her  body  rests,  should  also  have  several  fglds  of  blankets  or  other 
suitable  articles  placed  there,  to  protect  the  bed  from  the  discharges 
The  female  should   never,  under  any  circumstances,  be  exposed :  a 
sheet  or  blanket,  according  to  the  condition  of  the  weather,  should  be 
thrown  over  her.     And  in  order  to  facilitate  the  introduction  of  the 
blades,  lard  or  some  other  unctuous  substance  should  be  freely  applied 
to  the  soft  parts.     An  anesthetic  should  now  be  administered,  either 
by  the  obstetrician  in  charge  or  by  the  assistant,  providing  consulta- 
tion has  been  called. 

These  preliminary  measures  having  been  attended  to,  and  the 
operator  knowing  the  exact  position  of  the  head,  he  may  sit  or  stand,  as 
preferred,  and  proceed  to  introduce  the  blades.  These,  having  been 


KING'S  ECLECTIC  OBSTETRICS. 

previously  wanned  to  a  temperature  equal  to  that  of  the  patient,  by 
placing  them  in  warm  water,  are  to  be  well  greased,  and  each  blade  is 
to  be  held  in  its  appropriate  hand,  somewhat  similar  to  the  manner 
of  holding  a  pen,  although  rather  more  firmly — or  it  may  be  held  in 
the  manner  of  a  bistoury  while  making  an  incision.  Generally,  the 
male  blade,  or  the  one  introduced  by  the  left  hand,  ifi  applied  first, 
then  the  other ;  and  the  introduction  should  invariably  be  effected 
during  the  absence  of  labor-pains,  ceasing  all  efforts  when  these 
return. 

Some  writers  advise  that  blade  to  be  introduced  first  which  is 
applied  along  the  posterior  part  of  the  cavity,  and  this  will  probably 
hold  good  in  a  number  of  cases;  but,  as  a  general  rule,  it  will  be 
found  better,  in  practice,  to  introduce  that  blade  first  which  is  the  least 
easily  applied,  always  being  careful  to  so  apply  them  that  they  will 
readily  lock. 

Having  carefully  passed  in  two  or  three  fingers  of  the  hand  not 
occupied  in  holding  the  blade,  and  insinuated  them  between  the  os 
uteri  and  the  fetal  head,  both  as  a  guide  for  the  application  of  the 
blade,  and  to  prevent  the  os  uteri  from  being  included  in  the  grasp  of 
the  forceps,  each  blade  is  to  be  successively  and  carefully  passed  over 
the  sides  of  the  head.  If  the  head  is  high  up,  it  will  then  be  neces- 
sary to  introduce  the  whole  hand  within  the  vagina,  for  the  purpose  of 
properly  guiding  the  blades ;  and  the  direction  of  the  axes  of  the 
pelvis,  as  well  as  the  exact  position  of  the  head,  and  its  relations  to 
the  surrounding  parts,  should  not  fora  moment  be  lost  sight  of.  Ivich 
blade  must  be  passed  inward  with  a  waving  motion,  but  without  any 
force,  and  must  also  be  kept  in  constant  contact  with  the  head  during 
the  introduction.  Should  either  blade  meet  with  any  obstacle  to  its 
advance,  it  must  not  be  forcibly  thrust  forward,  but  should  be  passed 
beyond  the  difficulty  by -careful  and  adroit  management,  withdrawing 
the  blade,  if  necessary,  for  a  reintroduction ;  should  any  force  be 
employed  to  overcome  the  resistance,  the  ear,  or  a  fo,ld  of  the  skin,  or 
the  soft  parts  of  the  mother,  would,  probably,  be  torn,  and  which 
would  reflect  much  discredit  on  the  skill  and  attainments  of  the 
operator. 

As  a  general  rule,  the  forceps  are  to  be  applied,  with  their  concave 
surface  grasping  the  sides  of  the  head  in  the  direction  of  the  occipito- 
meutal  diameter;  and  they  are  always  to  be  so  applied,  that  at  the  ter- 
mination of  the  delivery,  when  the  head  is  emerging  from  under  the 
pubic  arch,  their  concave  edges  will  be  brought  under  and  facing  this 
arch.  By  considering  for  ajiioment,  whether  the  occiput  or  forehead 


RULES    FOR    APPLYING    THE    FORCLP.S.  605 

is  to  be  brought  under  the  pubic  arch,  the  practitioner  can  not  fail  to 
properly  apply  the  instrument,  for  the  concave  edges  of  the  blades 
must  always  be  directed  to  that  part  of  the  head  which  passes  under 
this  arch,  as  it  emerges  from  the  outlet. 

After  the  first  blade  has  been  applied,  it  may  be  held  by  an  assistant 
until  the  second  one  has  also  been  applied,  which  latter  should  be 
introduced  above,  and  as  nearly  as  possible  opposite,  the  handle  of 
the  male  blade,  in  order  that  they  may  lock  readily.  If  they  do  not 
lock  easily,  and  without  force,  no  rude  or  violent  attempts  at  twisting 
or  wrenching  them  round  should  be  made,  but  the  female  blade  should 
be  removed  and  reintroduced,  and  it  were  better  to  repeat  this  several 
times  than  to  attempt  an  adjustment  by  force.  Occasionally,  it  may 
become  necessary  to  withdraw  both  blades,  and  reapply  them.  When 
properly  locked,  a  finger  should  be  passed  around  the  lock  to  ascertain 
that  no  portion  of  the  soft  parts,  or  of  the  genital  hair,  are  fastened 
within  it. 

Having  effected  the  locking,  and  removed  any  hairs,  etc.,  which  may 
be  found  entangled  within  the  lock,  screw  down  the  pivot,  by  giving 
it  two  or  three  turns,  grasp  the  handles  firmly  and  make 'slight  com- 
pression and  traction,  to  ascertain  that  the  instrument  is  firmly  applied, 
and  that  no  part  of  the  vulva,  vagina,  or  os  uteri  is  included ;  and 
which  latter  circumstances  may  be  known  by  the  violent  pain  pro- 
duced— when  a  withdrawal  and  readjustment  of  the -instrument  will 
be  necessary. 

The  forceps  being  properly  applied,  the  operator  may  now  proceed 
to  deliver.  Seizing  the  handles  with  the  right  hand,  he  will  hold  them 
together  with  a  sufficient  degree  of  firmness  to  prevent  their  slipping 
from  the  head,  and  without  exerting  an  undue  compression  upon  it. 
The  left  hand  must  be  applied  over  the  lock  of  the  forceps,  with  the 
index  finger  extended  so  as  to  touch  the  vertex  of  the  child,  and  thus 
enable  him  to  ascertain  whether  the  head  advances  or  not  with  the 
motion  of  the  instrument.  If  it  does  not  advance,  the  finger  will  be 
found  to  leave  the  vertex  as  the  operation  proceeds. 

If  the  handles  are  held  in  the  left  hand,  the  right  should  be  applied, 
as  above,  to  the  lock ;  and  the  middle  finger  of  the  hand,  at  the  lock, 
may  be  placed  in  front  of  it,  that  is  on  the  part  facing  the  child's 
head,  to  aid  in  the  extraction,  should  more  extractive  force  be  required. 
The  index  finger  must  not  be  removed  from  the  head  until  it  emerges 
from  the  vulva ;  and  should  it  leave  the  head,  the  operator  must  cease 
action,  lest  the  blades  suddenly  slip  off,  and,  perhaps,  occasion  a  serious 
injury  to  the  parts. 


KINGS    ECLECTIC   OBSTETRICS. 

The  traction  should  always  be  made  in  the  direction  of  the  axis  of 
that  part  of  the  pelvis,  at  which  the  head  is  successively  placed,  and 
must  be  made  only  during  a  pain,  ceasing  in  its  absence;  or,  should 
the  pains  have  become  entirely  suspended,  the  operation  should  be 
continued  only  for  two  or  three  minutes  at  a  time,  allowing  intervals 
between  each  effort,  and  thus  imitating,  as  closely  as  possible,  the 
course  pursued  by  nature.  During  the  intervals  relax  the  handles, 
and  relieve  the  head  from  pressure. 

In  accomplishing  traction,  the  impulse  of  the  force  employed, 
although  guided  in  the  direction  of  the  pelvic  axis,  successively,  is 
effected  by  a  lateral  motion,  from  handle  to  handle,  keeping  the 
instrument  at  first,  as  far  back  to  the  perineum  as  possible,  in  order 
to  act  in  the  direction  of  the  axis  of  the  pelvic  brim  (if  this  be 
necessary),  and  elevating  the  handles  as  extension  ensues  and  the  head 
emerges  from  under  the  pubic  arch.  About  two-thirds  lateral  force, 
and  one-third  extractive  force  should  be  given;  and  the  nearer  the 
head  is  situated  toward  the  brim,  the  more  limited  will  be  the  extent 
of  the  motipn  from  side  to  side,  while  at  the  outlet  a  large  sweep  may 
be  taken. 

Most  usually  the  rotation  of  the  head  occurs  with  its  descent, 
carrying  the  forceps  along  with  it  as  it  rotates,  without  any  effort  of 
the  practitioner.  But  should  this  motion  of  rotation  not  be  effected 
naturally,  it  must  be  accomplished  by  the  operator,  not  by  violent 
exertions,  nor  by  twisting  the  head,  but  by  continuing  the  tractions 
from  handle  to  handle,  at  the  same  time  slowly  and  gradually  giving 
to  them  the  proper  direction  in  which  the  head  must  rotate. 

This  lateral  extractive  motion  causes  the  instrument  to  act  as  a 
double  lever,  and  in  effecting  the  change  in  the  motion  from  side,  to 
side,  the  operator  must  be  very  careful  to  retain  every  fraction  of  an 
inch  which  the  head  advances,  not  allowing  the  advance  made  by  one 
lateral  extractive  movement  to  recede  when  he  carries  the  handles  in 
an  opposite  direction.  Should  the  contractions  of  the  uterus  corne  on 
powerfully,  and  -the  head  commence  advancing  naturally,  after  a  few 
motions  of  the  instrument,  the  rest  of  the  labor  may  be  left  to  nature; 
but  the  forceps  must  not  be  removed  until  the  head  is  delivered, 
because,  if,  from  an  erroneous  view  of  the  natural  efforts,  the  removal 
of  the  blades  has  been  premature,  requiring  a  subsequent  reappli- 
cation,  it  places  the  operator  in  a  very  discreditable  and  mortifying 
position. 

As  the  head  passes  over  the  perineum,  this  must  be  carefully 
supported  by  an  assistant,  and  the  operator  should  slowly  and  care- 


RULES    FOR    APPLYING    THE    FORCEPS.  607 

fully  deliver  the  head,  requiring  the  patient  to  lie  still,  lest  any  sudden 
movement  on  her  part,  might  cause  a  severe  laceration  of  the  peri- 
neum. Generally,  when  the  head  reaches  the  outlet,  it  will  occasion 
tenesmus  and  sufficient  contraction  to  terminate  the  delivery,  without 
any  further  efforts  at  traction,  and  all  required  of  the  operator  will  be 
to  gradually  carry  up  the  handles  of  the  instrument  in  front  of  the 
pubis,  and  thus  favor  the  movement  of  extension ;  improper  traction 
at  this  time  will  almost  always  cause  a  rupture  of  the  perineum. 
But  should  there  be  any  difficulty  in  the  advance  and  extension  of 
the  head,  a  moderate  degree  of  traction  will  then  become  necessary. 
Remove  the  forceps  after  the  birth  of  the  head,  and  attend  to  the 
remainder  of  the  delivery,  the  same  as  in  a  natural  labor. 

Having  now  given  the  general  rules  for  the  employment  of  the 
forceps,  it  will  be  proper  to  refer  to  its  special  applications,  in  each 
position  of  the  head  or  face;  commencing  ¥  with  those  instances  in 
which  the  vertex  has  reached  the  inferior  strait. 

LEFT  OCCIPITO-ANTEKIOR  POSITION. 

This  position  (as  well  as  all  others)  should  be  positively,  and  cor- 
rectly ascertained  by  a  vaginal  examination ;  and  if  the  practitioner 
is  not  satisfied  with  the  signs  detected  by  the  finger  alone,  he  should 
not  hesitate  to  introduce  three  or  four  fingers,  or  even  the  whole  hand, 
extending  the  fingers  over  the  head,  and  ascertaining  its  true  position 
by  feeling  its  various  points. 

Having  the  patient  properly  situated,  he  will  take  the  male  or  left- 
hand  blade  of  the  forceps  in  his  left  hand,  and  using  two  or  three 
fingers  of  his  right  hand  as  a  guide,  he  will  carefully  introduce  it 
along  the  left  side  of  the  child's  head  and  in  front  of  the  maternal 
left  sacro-iliac  symphysis,  carrying  it  upward  until  the  extremity  of 
the  blade  reaches  the  chin  of  the  child.  When  the  blade  is  about 
to  be  introduced  at  the  vulva,  in  the  direction  of  the  axis  of  the 
inferior  strait,  the  handle  will  lie  in  an  oblique  manner  over  the  right 
groin  of  the  patient,  and  as  the  blade  passes  within  the  vagina,  being 
guided  in  the  direction  of  the  pelvic  axis,  the  handle  will  be  grad- 
ually depressed  between  the  woman's  thighs,  approaching  nearer  and 
nearer  toward  the  median  line.  When  properly  applied,  the  handle 
will  be  directed  toward  the  left  thigh  of  the  mother,  the  pivot  will 
look  upward  and  to  the  left,  and  the  concave  edge  of  the  blade  will 
be  directed  toward  the  left  acetabulum.  Having  an  assistant  to  hold 
this  blade,  the  operator  will  take  the  female  or  right-hand  blade  in 
his  right  hand,  and  with  the  fingers  of  his  left  hand  as  a  guide,  he 


608  KING-8    ECLECTIC   OBSTETRICS. 

will  introduce  it,  above  the  male  branch  and  nearly  opposite  to  it,  in 
front  of  the  right  foramen  ovale,  gradually  conducting  it  along  the 
side  of  the  head  in  the  occipito-mental  direction.  When  this  blade  is 
about  to  be  introduced,  the  handle  will  lie  obliquely  in  front  of  the 
left  groin,  and  as  the  blade  passes  within  the  vagina,  the  handle  will 
be  gradually  depressed  between  the  thighs  of  the  patient,  approaching 
by  degrees  toward  the  median  line.  As  soon  as  this  blade  has  entered 
to  a  sufficient  distance,  and  been  properly  adjusted  on  the  right  side 
of  the  head — both  blades  being  as  nearly  as  possible  in  the  direction 
of  the  occipito-mental  diameter  of  the  child's  head — they  will  lock 
without  any  difficulty.  When  locked,  both  handles  will  lie  toward 
the  left  thigh  of  the  patient,  that  of  the  male  blade  being  uppermost, 
and  the  pivot  will  be  directed  upward  and  to  the  left. 

The  head  being  at  the  inferior  strait,  as  soon  as  a  pain  comes  on, 
commence  the  traction  in  the  direction  of  the  axis  of  this  strait;  as 
the  head  advances  it  rotates,  the  concave  edges  of  the  foreep-blades 
are  brought  under  the  pubic  arch,  and  as  the  movement  of  extension 
takes  place,  the  handles  must  be  gradually  carried  upward  in  front  of 
the  pubic  ;  ymphysis  and  abdomen.  Accomplishing  the  remainder  of 
the  delivery  in  the  usual  way. 

EIGHT  OCCIPITO-ANTERIOR  POSITION. 

In  this  position  the  male  blade,  which,  in  all  cases,  is  to  be  held  in 
the  left  hand,  must  be  introduced,  along  the  fingers  of  the  right  hand, 
within  the  left  side  of  the  vagina,  and  by  means  of  a  spiral  movement, 
it  should  be  gradually  drawn  forward  so  as  to  apply  its  concave  surface 
to  the  left  side  of  the  child's  head.  The  handle  will  at  first  be 
inclined  obliquely  over  the  mother's  right  groin,  but  as  the  blade 
advances  it  will  gradually  be  depressed,  and  when  properly  adjusted, 
the  concave  edge  of  the  blade  will  look  toward  the  pubic  arch,  and 
the  pivot  will  be  directed  upward  and  toward  the  right  thigh.  De- 
pressing the  handle,  so  as  to  admit  the  introduction  of  the  opposite 
blade,  place  it  in  charge  of  an  assistant,  and  proceed  to  apply  Ihe 
other  blade.  Taking  it  in  the  right  hand,  and  with  the  fingers  of  the 
left  hand  as  a  guide,  introduce  it,  above  the  male  branch,  along  the 
right  side  of  the  head.  The  handle  of  this  blade  will  lie,  at  first, 
obliquely  in  front  of  the  left  groin,  but  is  depressed  as  the  blade  is 
entered  upward.  When  the  blades  are  properly  adjusted,  in  the 
occipito-mental  direction,  there  will  be  no  difficulty  in  locking,  and 
the  traction  will  be  made  as  in  the  preceding  instance. 


RULES    FOR    APPLYING    THE    FORCEPS. 


609 


FIG.  75 


OCC1PITO-PUBIC  POSITION. 

This  position  may  include  occipito-anterior  positions,  in  which  the 
movement  of  rotation  has  been  accomplished,  and  the  occiput  brought 
to  the  pubic  arch. 

In  this  position,  the  male  blade  will  be  taken  in  the  left  hand,  and, 
with  the  fingers  of  the  right  hand  as  a  guide,  must  be  introduced 
within  the  left  side  of  the  vagina,  along  the  left  side  of  the  child's 
head,  and  along  the  left  sacro-iliac  symphysis.  {Fig.  75.)  When  the 
blade  is  about  to  be  introduced  at  the  vulva,  in  the  direction  of  the 
axis  of  the  inferior  strait, 
the  handle  will  lie  in  an 
oblique  manner  over  the 
right  groin  of  the  patient, 
and  as  the  blade  passes 
within,  being  directed  in 
a  line  with  the  pelvic 
axis,  the  handle  is  grad- 
ually depressed, approach- 
ing nearer  and  nearer 
toward  the  median  line. 
When  properly  adjusted, 
the  handle  will  rest 
against  the  perineum,  the 
pivot  will  be  directed 
upward,  and  the  concave 
edge  of  the  blade  will  be 
under  the  pubic  arch. 
Placing  this  in  the  care 
of  an  assistant,  the  fe- 
male blade  being  held  in 
the  right  hand,  and  guided  by  the  fingers  of  the  left,  must  be 
cautiously  introduced,  above  the  male  blade  (Fig.  77),  as  far  within 
the  pelvis,  over  the  right  side  of  the  child's  head,  as  may  be  sufficient. 
The  handle,  which,  at  first,  was  obliquely  over  the  left  groin,  is  grad- 
ually depressed  as  the  blade  advances,  and  if  a  proper  application  has 
been  made,  the  two  branches  will  lock  very  readily,  the  concave  edge 
of  each,  as  well  as  the  pivot  being  directed  upward,  and  the  head  being 
grasped  by  the  blades  in  the  occipito-mental  direction.  (Figs.  78,  79.) 
The  traction  must  be  made  in  the  direction  of  the  inferior  pelvic  axis, 
39 


610 


KING'S  ECLECTIC  OBSTETRICS. 


that  is,  forward  and  downward,  and  as  soon  as  the  occiput  is  placed 
under  the  pubic  arch,  and  extension  takes  place,  the  handles  of  the 
instrument  will  gradually  rise  upward  and  toward  the  abdomen  of  the 
female. 


FIG.  76. 


A  reference  to  Fig.  76  indicates  the  grasp  of  the  forceps  in  an. 
oceipito-anterior  position  after  rotation.  It  is  not  always  possible  to., 
reach  the  occipito-mental  diameter,  and  when  forced  flexion  is  wanting 
the  forceps  will  usually  adjust  themselves  as  shown  in  the  above  cut, 

LEFT  OCCIPITO  POSTERIOR  POSITION. 

In  this  position  the  male  blade  will  be  introduced  within  the  left 
lateral  part  of  the  vagina,  along  the  right  side  of  the  child's  head, 
gradually  advancing  it  to  a  proper  adjustment  as  it  enters.  At  the 
commencement,  the  handle  will  lie  obliquely  over  the  right  groin, 
but  as  it  enters  it  is  depressed  until  the  blade  assumes  the  direction 
of  the  occipito-mental  diameter.  At  first,  this  direction  can  not  be 
exactly  obtained,  and  the  soft  parts  at  the  outlet  will  be  pressed  upon 
considerably ;  the  pivot  of  the  branch  will  look  upward  and  to  the 
right,  and  the  concave  edges  of  the  blades  will  look  toward  the  child's 
forehead.  An  assistant  holding  this,  the  operator  will  introduce  the 
female  blade  within  the  right  side  of  the  vagina,  and  along  the  left 
side  of  the  child's  head,  and  when  properly  applied  the  two  branches 
will  lock  readily,  with  the  pivot  directed  to  the  right  and  upward,  and 


RULES    FOR    APPLYING    THE    FORCEPS. 


611 


the  handles  will  be  depressed  as  far  backward  as  the  parts  will  allow. 
In  both  this  and  the  succeeding  position,  as  the  blades  can  not  be 
placed  exactly  along  the  occip-  FIG.  77. 

ito-mental  diameter  at  first, 
they  must  be  gradually  brought 
into  this  direction  as  extrac- 
tion proceeds,  being  careful 
not  to  bruise  or  injure  the  soft 
parts  of  the  mother,  or  the 
child's  head.  In  all  the  oc- 
cipito-posterior  positions,  after 
rotation  has  been  effected,  and 
the  forehead  brought  to  the 
pubic  arch,  the  remaining  de- 
livery of  the  head  will  be 
accomplished  in  the  same  man- 
ner as  mentioned  in  the  occip- 
ito-sacral  position.  And,  when 
the  head  is  near  the  inferior 
strait,  no  attempts  must  be 
made  to  rotate  the  occiput 
under  the  pubic  arch  before  extracting,  lest  the  child's  neck  be  dis- 
located ;  though  careful  efforts  may  be  made  to  bring  the  vertex  into 
the  hollow  of  the  sacrum. 

RIGHT  OCCIPITO-POSTERIOR  POSITION. 
FIG.  78. 

In  this  position  the  blades 

will  be  introduced  some- 
what similar  to  the  mode 
laid  down  under  the  right 
occipito- anterior.  When 
the  branches  are  correctly 
adjusted  and  locked,  the 
soft  parts  will  be  consid- 
erably pressed  upon,  the 
pivot  will  look  upward  and 
to  the  left,  the  handles  will 
be  very  much  depressed, 
and  the  blades,  as  in  the 
preceding  position,  will  not  at  first  be  exactly  in  the  occipito-mental 


612 


KING'S    ECLECTIC   OBSTETRICS. 


direction.  (Fig.  80.)  Traction  and  rotation  having  brought  the 
forehead  under  the  pubic  arch,  the  remainder  of  the  operation  will  be 
the  same  as  in  the  occipito-sacral  position. 

OCCIPITO-SACRAL  POSITION. 

In  this  position  the  blades  are  to  be  applied 
somewhat  similar  to  the  manner  named  under 
the  occipito-pubic,  but  with  the  concave  edges 
of  the  blades  looking  toward  the  child's  /ore- 
head  instead  of  its  occiput.  When  properly 
adjusted,  the  concave  edges  of  the  blades  will 
be  directed  toward  the  pubic  arch,  the  pivot 
will  look  upward,  and  the  handles  will  be  de- 
pressed so  far  backward  upon  the  perineum  as 
frequently  to  produce  a  degree  of  pain.  The 
traction,  in  this  instance,  as  well  as  in  the  two 
preceding  positions,  after  rotation  has  been 
effected,  is  not  to  be  made  in  the  direction  of 
the  pelvic  inferior  axis.  The  occiput  will  have 
to  be  the  first  delivered,  and  to  accomplish  this 
it  must  traverse  over  the  sacrum  and  perineum.  The  handles  will, 
therefore,  at  first,  be  carried  upward  so  as  to  produce  increased  flexion, 
and  bring  the  occipito-mental  diameter  FIQ.  so. 

parallel  with  the  axis  of  the  inferior 
strait.  This  will  advance  the  occiput 
over  the  posterior  commissure  of  the 
vulva,  when  the  handles  must  be  de- 
pressed in  order  to  permit  the  extension 
of  the  head  to  take  place,  which  termi- 
nates the  operation. 

As  in  these  occipito-posterior  posi- 
tions the  perineum  is  greatly  dilated, 
the  operator  must  proceed  very  patiently 
and  carefully,  being  especially  observant 
that  the  proper  support  be  given  to  it 
as  the  head  is  passing  over,  lest  it  be 
lacerated.  After  the  occiput  has  been 
delivered,  should  there  be  a  delay  in  the  extension,  as  the  instrument 
is  depressed,  a  sufficient  degree  of  traction  downward  and  backward 
may  be  made,  to  enable  the  forehead,  face,  and  chin,  to  pass  from 


RULES    FOB   APPLYING   THE    FORCEPS.  613 

under   the   pubic   arch.     The   rest   of  the  labor  is  terminated  as  in 
ordinary  cases. 


FIG.  81. 


Fig.  81  shows  the  forceps  applied  in  an  occipito-posterior  position 
after  rotation. 

LEFT  OCCIPITO-TRANSVERSE   POSITION. 

Occasionally  the  head  will  be  found  lying  transversely  within  the 
pelvic  cavity;  the  occiput  may  be  directed  toward  one  ischium,  and 
the  forehead  toward  the  other.  In  the  present  position,  the  occiput 
will  lie  against  the  left  ischium,  and  the  forehead  against  the  right,  in 
a  line  with  the  transverse  diameter  of  the  pelvis.  In  each  transverse 
position  the  rotation  must  bring  the  occiput,  and  consequently  the 
concave  edges  of  the  forcep-blades,  to  the  arch  of  the  pubes,  and  by 
recollecting  this,  it  may  at  once  be  determined  how  to  apply  the  blades. 

In  the  left  occipito-transverse  position,  the  male  blade  will  be  applied 
to  the  lower  and  left  side  of  the  child's  head,  after  which  the  female 
blade  will  be  applied  to  its  upper  and  right  side.  In  order  to  effect 
the  application  with  as  little  difficulty  as  possible,  pass  the  male  blade 
within  the  left  lateral  and  posterior  part  of  the  vagina,  along  the  left 
sacro-iliac  symphysis,  and  when  it  has  entered  sufficiently,  carefully 
move  the  blade  to  the  hollow  of  the  sacrum,  and  its  concave  surface 
will  be  over  the  left  side  of  the  child's  head.  Having  an  assistant  to 


614  KING'S  ECLECTIC  OBSTETRICS. 

hold  this,  introduce  the  female  blade  along  the  right  anterior  part  of 
the  pelvis,  behind  the  right  acetabulum,  and  by  gentle  efforts  work  it 
gradually  to  the  symphysis  pubis,  that  its  concave  surface  may  be 
applied  over  the  right  side  of  the  child's  head.  When  the  blades  are 
properly  adjusted,  they  will  lock  without  any  difficulty,  and  the  pivot 
will  be  directed  toward  the  left  thigh  of  the  mother. 

Traction  must  now  be  made  in  the  direction  of  the  pelvic  axis 
corresponding  to  that  part  of  it,  however,  in  which  the  head  is  situated, 
and  at  the  same  time  rotation  from  left  to  right  should  be  slowly  and 
gently  attempted.  When  this  has  been  effected,  the  remainder  of  the 
delivery  will  be  terminated  in  the  usual  manner. 

Professor  Meigs  observes,  that  in  this  position,  when  the  male 
branch  is  introduced  as  above,  the  handle  is  strongly  abducted  toward 
the  left  thigh  and  interferes  with  the  depression  and  consequently  the 
application  of  the  female  branch,  and  to  avoid  this  difficulty,  he 
advises  the  female  blade  to  be  the  first  introduced.  His  method  of 
application  is  thus :  "Take  the  female  or  upper  blade  in  the  right 
hand,  and  introduce  it  into  the  posterior  and  right  side  of  the  vagina, 
conducting  its  point  as  near  as  may  be  to  the  chin,  and  over  the  face 
to  the  right  side  of  the  head  behind  the  pubis,  leaving  the  handle  to 
project  toward  the  left  thigh.  Next,  take  the  male  blade  into  the 
right  hand,  and,  turning  the  concave  edge  of  the  new  curve  down- 
ward, insert  the  point  into  the  right  side  of  the  vagina,  below  the 
female  branch.  Let  the  fetal  face  of  the  .clamp  apply  itself  to  the 
convexity  of  the  head,  and  slide  it  onward,  and,  in  proportion  as  it 
enters,  make  it  sweep  round  the  crown  of  the  head  toward  the  back 
of  the  pelvis.  In  effecting  this,  the  handle  comes  gradually  down  as 
the  clamp  gets  on  the  left  side  of  the  cranium,  and  at  last  the  lock  is 
found  to  be  where  it  ought  to  be,  namely,  under  the  upper  or  female 
blade,  with  which  it  is  then  locked."  This,  undoubtedly,  appears  to 
be  the  better  method  of  introducing  the  blades,  but,  as  with  all  other 
cases,  the  practitioner  who  is  well  versed  in  the  general  principles  of 
these  operations  will  be  governed  by  the  peculiar  circumstances 
attending  each  individual  case. 

EIGHT  OCCIPITO-TRANSVERSE  POSITION. 

In  this  position  the  head  lies  in  the  direction  of  the  pelvic  trans- 
verse diameter,  the  occiput  resting  against  the  right  ischium,  and  the 
forehead  against  the  left.  The  application  of  the  forceps  is  similar  to 
the  preceding,  with  the  exception  that  the  female  blade  must  be 


MODE   OF    APPLYING   THE    FORCEPS    AT    THE    BRIM.  615 

applied  to  the  right  side  of  the  child's  head,  along  the  posterior  part 
of  the  pelvis,  while  the  male  blade  must  be  over  the  left  side  of  the 
head  and  behind  the  pubic  symphysis.  The  male  branch  is  generally 
the  first  introduced,  though  some  authors  advise  the  female.  As  before 
stated,  it  will  commonly  be  found  more  advantageous  to  enter  that 
blade  first,  which  is  of  the  most  difficult  application,  being  particular, 
however,  that  the  introduction  be  so  managed  as  to  cause  no  difficulty 
in  the  locking. 

The  same  manipulation  will  be  required,  as  in  the  preceding 
position,  excepting  that  the  rotation  must  be  made  from  right  to 
left,  in  order  to  carry  the  occiput  under  the  pubic  arch ;  this  accom- 
plished, the  labor  must  be  terminated  as  usual. 

Trouble  in  locking  the  forceps  is  sometimes  encountered  in  occipito- 
anterior  or  posterior  positions,  due  to  the  ends  of  the  blades  coming 
in  contact  with  the  maternal  sacrum.  A  lowering  of  the  handles  will 
render  it  possible*  to  introduce  them  higher  in  the  pelvis,  and  thus 
readily  overcome  the  difficulty. 


CHAPTER    XLV. 

MODE    OF   APPLYING    THE    FORCEPS    AT    THE    BRIM — IN    FACE    PRES- 
ENTATIONS,   AND    IN    PELVIC    PRESENTATIONS. 

WHEN  the  HEAD  IS  AT  THE  SUPERIOR  STRAIT,  the  pel- 
vis being  of  normal  size,  and  circumstances  occur  requiring  the 
delivery  to  be  expedited,  turning  should  always  be  preferred  to  the 
use  of  the  forceps.  But  when  the  head  has  engaged  in  this  strait  and 
descended  so  low  as  to  render  the  operation  of  turning  impossible,  the 
os  uteri  being  dilatable,  and  immediate  delivery  necessary,  the  long 
forceps  may  be  frequently  employed  with  advantage,  even  though  the 
head  has  not  advanced  so  far  within  the  cavity,  as  to  enable  an  ear  to 
be  felt.  They  may  likewise  be  applied  with  benefit  in  cases  where  the 
antero-posterior  diameter  of  the  superior  strait  is  only  three  and  one- 
fourth  or  three  and  a  half  inches,  and  the  natural  efforts  are  insuf- 
ficient to  advance  the  head.  To  these  conditions,  therefore,  should 
the  application  of  the  forceps  at  the  brim  be  limited. 


616  KING'S  ECLECTIC  OBSTETRICS. 

It  must  not  be  supposed  that  an  operation  at  the  brim,  with  this 
instrument,  is  an  easy  one ;  on  the  contrary  it  is  both  difficult  and 
hazardous.  The  position  of  the  head  above  the  brim  can  not  be  « 
easily  ascertained,  and  if  it  could  be,  it  would  make  but  little  dif- 
ference, as  the  forceps  can  be  applied  only  along  the  sides  of  the 
pelvis;  consequently,  the  head  may  be  grasped  by  the  blades  in  its 
bi-parietal  diameter,  or  in  its  occipito-frontal,  the  latter  more 
frequently.  The  mobility  of  the  head,  when  not  held  by  the  brim, 
also  renders  the  adjustment  of  the  blades  a  troublesome  matter,  and 
frequently,  their  hold  on  the  head  being  imperfect,  as  soon  as  tractions 
are  made,  they  may  suddenly  slip  and  seriously  injure  the  cervix. 
Hence,  when  it  becomes  necessary  to  use  the  instrument  at  this 
point,  the  operator  should  proceed  carefully  and  judiciously. 

The  diiference  between  the  application  of  the  forceps  at  the  brim, 
and  at  the  outlet,  is,  that  in  the  former,  the  whole  hand  must  be  carried 
within  the  vagina,  and  two  or  three  fingers  be  passed  as  high  up  as 
possible  between  the  cervix  and  head  of  the  child,  and  the  instrument 
is. to  be  introduced  along  the  sides  of  the  pelvis,  so  that  a  blade  will 
be  applied  within  each  ilium.  When  properly  adjusted  they  will  lock 
more  or  less  readily,  and  the  handles  will  be  depressed  backward  as 
far  as  possible,  that  the  blades  may  take  the  direction  of  the  superior 
pelvic  axis.  Sufficient  compression  should  be  exerted  on  the  handles 
to  hold  the  head  securely,  and  the  traction  should  be  made,  as  in  the 
other  instances,  not  by  sudden,  short  jerks,  nor  by  any  forcible  meas- 
ures, but  by  a  full,  slow,  regular  motion  from  handle  to  handle,  making 
traction  in  the  direction  of  the  axis  of  the  brim. 

If  the  instrument  does  not  lock  readily,  no  force  or  twisting  must 
be  used  to  effect  it,  but  the  operator  should  withdraw  the  blade  last 
introduced  and  reapply  it;  and  this  had  better  be  repeated  several 
times,  than  to  endanger  laceration  of  the  cervix  or  soft  parts  by 
forcible  and  unnecessary  endeavors  to  lock  the  branches. 

Should  the  head  lie  with  one  parietal  protuberance  resting  on  the 
pubis,  and  the  other  on  the  sacral  promontory,  the  forceps  will  be 
applied  with  one  blade  over  the  occiput,  and  the  other  over  the  fore- 
head, or,  perhaps,  over  the  face.  Should  the  traction  and  lateral 
motions  communicated  to  the  instrument  cause  the  head  to  take  a 
diagonal  position  and  descend  into  the  pelvic  cavity,  the  blades  may 
be  withdrawn,  provided  the  natural  efforts  are  sufficient  to  conclude 
the  labor;  if  not,  the  blades  must  be  readjusted,  but  this  time  on  the 
sides  of  the  head. 


MODE  OF  APPLYING  THE  FORCEPS  IN   FACE  PRESENTATIONS.       617 

If,  after  having  used  a  justifiable  force  iu  the  operation,  we  find  it 
impossible  to  advance  the  head,  or  at  least  without  exerting  a  power 
which  would  unnecessarily  expose  the  mother  to  dangers,  it  then  be- 
comes our  duty  to  either  resort  to  the  perforator  or  Cesarean  section ; 
if  the  decision  is  in  favor  of  the  perforator,  and  a  delay  would  not 
add  to  the  mother's  risk,  the  operator  need  not  act  until  the  steth- 
oscope determines  the  child's  death.  We  are  never  to  save  the  life  of 
the  child  at  the  expense  of  the  mother's;  and,  in  most  cases,  the  death 
of  the  child  can  be  determined  by  the  stethoscope  in  sufficient  time 
for  the  mother's  safety,  before  using  the  perforator. 

When  the  occiput  is  fastened  behind  the  pubis,  and  the  forehead  is 
in  front  of  the  sacral  promontory,  the  blades  will  then  pass  over  the 
sides  of  the  head ;  and  when  this  is  ascertained  to  be  the  case,  the 
operator  may  exert  more  force  than  before,  and  probably  the  difficulty 
Avill  be  more  readily  overcome.  When  the  head  is  locked  at  the  brim, 
De\vees  advises  us — after  having  applied  the  forceps — to  first  elevate 
the  head,  by  gently  carrying  the  handles  from  side  to  side,  at  the  same 
time  pushing  the  instrument  upward.  This  may  be  beneficial  in  some 
cases,  bat  usually,  where  the  operation  will  prove  successful,  as  the 
handles  are  rotated  from  side  to  side  with  sufficient  traction,  the  head 
disengages,  rotates,  if  necessary,  to  the  oblique  diameter,  and  descends 
into  the  pelvic  cavity. 

The  forceps  may  sometimes  be  required  in  FACE  PRESENTA- 
TIONS, in  which  case  the  blades  are  to  be  applied  over  the  ears  of 
the  child,  similar  to  the  manner  named  in  vertex  presentations ;  being 
careful  so  to  adjust  them  as  to  bring  the  chin  toward  the  pubic  arch. 
And  in  all  operations  when  the  face  presents,  the  operator  should 
proceed  slowly,  so  as  to  permit  the  body  to  undergo  a  rotation,  and 
thus  prevent  a  twisting  or  dislocation  of  the  neck. 

LEFT  MENTO-ILIAC  POSITION.— (Fig.  82.) 

As  the  chin  is  the  part  to  be  brought  to  the  pubic  arch  in  this  posi- 
tion, the  male  or  lower  blade  will  be  passed  in  front  of  the  sacrum,  and 
over  the  right  side  of  the  child's  head,  as  much  as  possible  in  the 
occipito-mental  direction.  An  assistant  holding  this,  the  female 
branch  will  be  gradually  insinuated  anteriorly,  over  the  left  side  of 
the  child's  head,  and  when  the  two  are  properly  adjusted  they  will 
readily  lock.  The  concave  edges  of  the  blades  will  then  be  directed 
to  the  left  of  the  pelvis,  and  the  pivot  will  look  toward  the  maternal 
left  thigh ;  both  of  these  may  also  be  directed  upward,  if,  instead  of  a 


618 


KING'S    ECLECTIC    OBSTETRICS. 


FIG.  82.  complete  transverse  position,  the  chin 

is  placed  somewhat  anteriorly,  in  a  line 
with  the  oblique  diameter  of  the  pelvis. 
The  handles  must  then  be  rotated  from 
below  upward,  and  from  left  to  right, 
gradually  bringing  the  chin,  as  well  as 
the  concave  edges  of  the  blades,  under 
the  pubic  arch  :  this  having  been  ef- 
fected, traction  must  be  made  directly 
forward  and  slightly  downward,  to  free 
the  chin  from  under  the  arch,  after 
which  the  handles  must  be  slowly  ele- 
vated to  gradually  flex  the  chin,  and 
which  motion  causes  the  head  to  pass 
successively  over  the  hollow  of  the 
sacrum,  perineum,  and  posterior  com- 

missure of  the  vulva,  while  at  the  same  time  the  several  parts  of  the 

face  are  disengaged  in  succession. 

EIGHT  MENTO-  ILIAC  POSITION* 

In  this  position  the  operation  will  be  very  nearly  similar  to  the 
preceding  one  ;  the  female  blade  will  be  the  first  applied  along  the 


*  MENTO-PUBIC   POSITION. 

The  chin  being  placed  at  the  symphysis  pubis,  and  the  forehead  at  the  sacrum.  In 
this  position,  or  when  the  face  has  assumed  it,  the  head  having  descended  into  the 
pelvic  cavity  and  performed  its  movement  of  rotation,  the  forceps  may  be  more  easily 
applied  than  in  the  two  preceding  positions.  The  male  blade  must  be  applied  along 
the  left  side  of  the  pelvis,  grasping  the  right  side  of  the  child's  head,  and  the  female 
blade  must  be  passed  along  the  right  side  of  the  pelvis  to  grasp  the  left  side  of  the 
child's  head.  Traction  forward  and  slightly  downward  must  then  be  made,  to  disen- 
gage the  chin  from  under  the  pubic  arch,  after  which,  elevate  the  handles,  thereby 
effecting  at  the  same  time  flexion  and  the  liberation  of  the  head.  Indeed,  this  is  but 
a  repetition  of  what  has  already  been  stated  above;  but,  as  a  matter  of  reference,  il 
has  been  deemed  better  to  retain  it. 

MENTO-SACRAL   POSITION. 

The  chin  being  placed  at  the  sacrum,  and  the  forehead  at  the  symphysis  pubis. 
This  is  a  position  with  which  I  have  never  met;  and  were  it  not  that  cases  have  been 
recorded  by  individuals  of  eminence  and  undoubted  authority,  I  should  be  very  much 
inclined  to  doubt  the  possibility  of  its  occurrence,  except,  perhaps,  in  case  of  a  very 
small  child  passing  through  an  exceedingly  large  pelvis. 

However,  should  such  a  position  be  met  with,  requiring  the  use  of  the  forceps,  it  is 
recommended  to  introduce  the  male  blade  along  the  left  side  of  the  pelvis  and  on  the 
left  side  of  the  child's  head,  and  the  female  blade  along  the  right  side  of  the  pelvis  on 


MODE  OF  APPLYING  THE  FORCEPS  IN  FACE  PRESENTATIONS.     619 

posterior  part  of  the  pelvis  to  the  left  side  of  the  child's  head,  while 
the  male  blade  will  be  carefully  guided  over  the  right  side.  When 
correctly  adjusted,  they  will  lock,  the  pivot  being  directed  toward  the 
mother's  right  thigh.  Rotation  may  be  made  from  below  upward  and 
from  right  to  left,  until  the  chin  is  brought  to  the  pubic  symphysis, 
when  the  rest  of  the  operation  will  be  the  same  as  in  the  one  previous. 
In  each  of  these  mento-iliac  positions,  should  the  face  not  have 
arrived  at  the  inferior  strait,  it  will  be  proper  to  conduct  it  there  by 
tractions  and  lateral  motions,  the  same  as  in  vertex  presentations;  after 
which  operate  as  recommended.  Some  authors  reverse  the  order  of 
introducing  the  blades,  preferring  to  use  the  male  blade  first,  in  the 
right  mento-iliac  position,  and  the  female,  first,  in  the  left  mento-iliac. 
The  operator  will  employ  his  own  judgment  in  this  matter,  always 
bearing  in  mind  the  rule  to  enter  the  blade  of  more  difficult  applica- 
tion first. 

The  FACE  MAY  BE   ABOVE  THE  SUPERIOR   STRAIT, 

and  movable.  If  the  methods  heretofore  advised  for  changing  it  to 
a  vertex  presentation  do  not  succeed,  and  pelvic  version  can  not  be 
accomplished,  it  has  been  recommended  to  attempt  the  delivery  by  the 
forceps.  This,  however,  will  more  frequently  be  found  impracticable, 
the  perforator  being  required  in  the  majority  of  instances.  When  the 
head  is  thus  situated  above  the  brim,  the  face  usually  presents  in  a 
transverse  direction,  and  the  forceps  would  have  to  be  applied  with, 
one  blade  over  the  forehead  and  top  of  the  head,  and  the  other  over 
the  chin,  pressing  upon  the  child's  neck ;  so  that,  beside  the  danger  of 
the  blades  slipping  from  these  parts,  any  efficient  degree  of  compression 
or  traction  would  almost  certainly  occasion  the  death  of  the  child. 

The  same  may  be  said  of  those  cases  where  the  HEAD  HAS 
PARTLY  ENTERED  THE  SUPERIOR  STRAIT;  but  there  is  a 
greater  possibility  of  success,  if  the  blades  can  be  applied  n.pon  the 
sides  of  the  head ;  in  which  case  the  mode  of  application  will  be  the 
same  as  in  the  preceding  face  positions.  In  each  of  the  above  condi- 
tions it  will  be  necessary  to  introduce  the  whole  hand  within  the 
vagina,  as  a  guide  to  the  forcep-blades. 

In  the  last  condition,  the  head  being  partly  within  the  cavity  and 

the  right  side  of  the  head.  When  properly  adjusted,  the  handles  will  be  strongly 
depressed  against  the  perineum.  The  face  having  reached  the  outlet,  the  handles 
must  at  first  be  elevated  so  as  to  pass  the  chin  over  the  perineum  and  posterior  com- 
missure; this  having  been  accomplished,  depress  the  handles,  which,  with  a  degree  of 
traction,  will  flex  the  chin,  and  disengage  the  head  from  its  position  at  the  pubes. 


620  KING'S  ECLECTIC  OBSTETRICS. 

partly  within  the  brim,  but  with  the  CHIN  DIRECTED  TO  THE 
SACRUM,  and  it  being  impossible  to  change  the  position  to  a  vertex 
presentation,  or  to  accomplish  pelvic  version,  it  has  been  recom- 
mended to  slowly  and  carefully  rotate  the  chin  to  the  pubis,  as  the 
head  is  made  to  descend  by  the  forceps.  I  consider  this  not  only  a 
difficult  task,  but  almost  an  impossibility,  at  least  as  far  as  safety  to 
the  child  is  concerned;  and,  as  a  general  rule,  when  it  becomes  neces- 
sary to  expedite  delivery  in  these  cases,  I  believe  it  will  be  found  that 
the  perforator  will  ultimately  be  required  before  the  labor  can  be 
terminated. 

In  PELVIC  PRESENTATIONS,  or  in  cases  where  pelvic  version 
has  been  performed,  it  not  unfrequently  occurs,  that  after  the  expul- 
sion of  the  body,  there  is  a  delay  or  difficulty  attending  the  delivery 
of  the  head,  in  which  cases,  should  the  accoucheur  not  be  able  to 
remove  the  obstruction  by  flexing  the  head  with  his  hand,  as  hereto- 
fore described,  he  will  have  to  employ  the  forceps.  Hence,  as  a  very 
short  delay  may  prove  fatal  to  the  child,  the  most  prudent  course  to 
adopt,  in  all  these  labors,  is  to  have  the  instrument  at  hand  at  as  early 
a  period  as  possible,  after  their  character  has  been  ascertained. 

In  these  labors,  the  head  may  be  found  in  one  of  two  positions, 
viz.:  with  the  occiput  to  the  pubic  arch,  and  the  face  in  the  hollow  of 
the  sacrum,  and  which  is  always  the  most  desirable  position ;  or,  with 
the  face  to  the  pubis  and  the  occiput  in  the  hollow  of  the  sacrum — a 
most  undesirable  position.  If  the  forceps  be  required  to  deliver  the 
head,  the  rules  for  operating  are  similar  to  those  given  in  vertex  pre- 
sentation, thus: 

OCCIPITO-PUBIC  POSITION. 

In  which  the  occiput  is  to  the  pubis,  and  the  face  to  the  sacrum. 
Carefully  envelop  the  arms  and  body  of  the  child  in  a  -napkin,  and 
carry  it  upward,  or  toward  the  mother's  abdomen,  but  not  so  far  as  to 
endanger  its  neck  ;  then,  let  an  assistant  hold  the  child  in  this  position, 
that  its  body  may  not  be  in  the  way  of  the  operator.  The  latter 
having  introduced  two  or  three  fingers  of  his  right  hand  along  the 
inferior  and  left  side  of  the  vagina,  as  a  guide  to  the  forcep-blades, 
will,  with  his  left  hand,  carefully  apply  the  blade  of  the  male  branch 
upon  the  right  side  of  the  child's  head.  Then  intrust  this  to  the  care 
of  an  assistant,  who  will  depress  it  somewhat  to  permit  the  applica- 
tion of  the  female  blade.  This  will  be  introduced,  being  held  by  the 
right  hand,  and  guided  by  the  fingers  of  the  left  hand,  along  the 


MODE  OF  APPLYING  THE  FORCEPS  IN  PELVIC  PRESENTATIONS.    621 

inferior  and  right  side  of  the  vagina,  and  thence  upon  the  left  side 
of  the  head.  When  properly  applied,  the  forcep-blades  will  grasp 
the  head  in  its  occipito-mental  diameter,  and  will  lock  readily. 
Holding  the  instrument  in  the  manner  heretofore  recommended,  the 
operator  will  commence  his  tractions  and  oscillatory  movements,  and 
as  the  head  emerges  the  handles  must  be  gradually  elevated,  the  same 
as  in  occipito-anterior  positions,  by  which  the  chin,  face,  forehead, 
and  vertex,  successively,  pass  over  the  perineum  and  posterior  com- 
missure, and  the  delivery  will  be  thus  terminated. 

Should  the  occiput  be  directed  to  the  left,  or  right  lateral-anterior 
portion  of  the  pelvis,  the  operator  will  be  governed  by  the  above 
rules,  as  well  as  those  named  for  occipito-anterior  positions,  being 
careful  to  so  introduce  the  blades,  that,  at  the  termination  of  the 
delivery,  their  concave  edges,  together  with  the  child's  occiput,  will 
be  brought  under  the  pubic  arch. 

OCCIPITO-SACEAL  POSITION. 

In  which  the  face  is  to  the  pubis,  and  the  occiput  to  the  sacrum. 
This  is  a  very  unfortunate  position,  and  one  which  may  prove  very 
painful  to  the  female,  and  troublesome  to  the  practitioner.  Although 
it  is  more  frequently  the  result  of  ignorance,  or  want  of  skill,  on  the 
part  of  the  accoucheur,  yet  it  will  sometimes  occur  in  the  hands  of 
the  most  skillful.  In  this  position,  the  body  of  the  child  being  en- 
veloped in  a  cloth,  as  before,  must  be  carried  backward,  so  that  its 
back  will  rest  against  the  perineum  of  the  mother.  The  blades  are 
introduced  as  in  the  previous  position,  in  front  of  the  child's  thorax, 
the  male  blade  along  the  left  side  of  the  pelvis,  and  on  the  left  side 
of  the  child's  head,  and  the  female  blade  along  the  right  side  of  the 
pelvis,  and  on  the  right  side  of  the  child's  head.  The  instrument 
being  properly  applied,  and  the  head  brought  to  the  outlet,  instead  of 
elevating  the  handles  to  pass  the  occiput  over  the  perineum,  they  must 
be  strongly  depressed  downward,  with  sufficient  traction,  so  as  to 
cause  the  chin,  face,  forehead,  and  vertex  to  pass  successively  from 
under  the  pubic  arch,  while  at  the  same  time  the  occiput  is  made  to 
revolve  on  its  axis,  in  front  'of,  and  upon  the  perineum. 

If  the  occiput  be  directed  to  the  left,  or  right  lateral-posterior 
portion  of  the  pelvis,  the  above  rules,  together  with  those  given  in 
occipito-posterior  positions,  will  be  sufficient  to  guide  the  educated 
practitioner. 

In  addition  to  the  preceding  instances,  the  forceps  have  been  found 


<622  KING'S  ECLECTIC  OBSTETRICS. 

occasionally  advantageous  in  irregular  presentations  of  the  head,  as  of 
the  ear,  forehead,  etc.,  in  which  manual  endeavors  to  correct  the 
position  have  failed;  and  also  in  some  cases  of  diminished  size  of  the 
diameters  of  the  inferior  strait.  Whatever  circumstances  may  present 
during  labor,  requiring  a  resort  to  the  forceps,  the  practitioner  will 
apply  them  according  to  the  peculiar  nature  of  the  case,  being,  how- 
ever, always  governed  by  the  rules  already  explained. 


CHAPTER    XLVI. 

CRANIOTOMY PERFORATOR — CROTCHET CESAREAN     OPERATION— 

SYMPHYSEOTOMY. 

CRANIOTOMY  is  an  operation  by  which  the  life  of  the  child  is 
destroyed,  for  the  purpose  of  preserving  that  of  the  mother;  it  is  also 
employed  in  some  cases  when  the  child  is  dead.  The  terms  embry- 
ulcia,  embryotomy,  and  cephalotomy,  have  been  applied  to  this 
operation;  while  the  terms  evisceration,  exvisceration,  and  exenter- 
ismus,  have  reference  to  the  removal  of  the  contents  of  the  trunk. 

As  has  been  heretofore  named  and  repeated,  the  safety  of  the  mother 
is  the  first  and  essential  consideration  in  the  practice  of  obstetrics,  and 
if,  in  order  to  insure  this,  it  becomes  necessary  to  sacrifice  the  child, 
however  painful  or  revolting  to  the  feelings  of  the  operators  this 
unpleasant  task  may  be,  he  must  not  shrink  from  his  duty,  nor  hesitate 
to  adopt  every  measure  in  consonance  with  the  preservation  of  his 
patient.  Beside,  it  must  be  recollected  that  the  death  of  the  child  is 
certain,  in  cases  where  craniotomy  is  admissible ;  it  can  not  be  saved 
by  any  means,  unless  we  except  the  Cesarean  operation,  which  proves 
fatal,  on  an  average,  to  the  child  once  in  every  3J  cases — to  the  mother 
once  in  every  2£.  The  operation  of  craniotomy  is  not  to  be  under- 
taken heedlessly,  nor  without  due  consideration,  and  a  proper  consul- 
tation with  one  or  more  experienced  accoucheurs;  and  is  only  to  be 
attempted  when  both  mother  and  child  would  be  destroyed,  were  the 
labor  left  to  the  natural  efforts,  and  when  version,  or  delivery  by  the 
forceps  can  not  be  accomplished,  and  the  pelvic  diameters  are  sufficiently 
spacious  to  permit  the  extraction  of  the  mutilated  infant. 

According  to  Churchill,  craniotomy  has  been  performed  in  British 
practice  270  times  in  54,485  cases  of  labor,  or  about  1  in.  201f ;  in 


CRANIOTOMY.  623 

French  practice  30  times  in  36,169  labors,  or  1  in  l,205f ;  in  German 
practice  132  times  in  256,655  labors,  or  1  in  1,944J;  making  a  total 
of  347,309  labors,  in  which  the  operation  was  performed  in  432,  or 
about  1  in  803f.  The  results  to  the  mother  have  been  60  de.aths  in 
303  craniotomy  cases,  or  about  1  in  5.  The  operation,  therefore,  as 
compared  with  the  employment  of  the  forceps,  is  less  favorable ;  and 
much  of  this  mortality  may  be  owing  to  the  fact,  that  the  feeling  and 
humane  obstetrician  being  unwilling  to  take  the  life  of  the  child,  even 
in  so  justifiable  a  cause,  has  hesitated  to  perforate  until  assured  of  its 
death ;  and  the  delay  thus  occasioned  has  rendered  the  operation  much 
more  unfavorable  to  the  mother,  than  if  it  had  been  earlier  undertaken. 

Perforation  of  the  fetal  skull  is  generally  advised  in  cases  of  dimin- 
ished pelvic  diameters,  but  the  degree  of  this  diminution  is  not  posi- 
tively settled.  Thus,  Dr.  Osborn  considers  the  operation  necessary 
when  the  antero-posterior  diameter  is  not  less  than  2f  inches.  The 
smallest  diameter  through  which  a  living  child  can  pass,  is  stated  by 
Dr.  Clarke,  to  be  3 J  inches ;  by  Dr.  Burns  3J ;  by  Dr.  Le  Eoy  3J ;  by 
Dr.  Atkin  3;  by  Dr.  Ritgen  2;  these  differences  of  opinion  have, 
probably,  resulted  from  the  various  sizes  of  the  fetal  heads  met  with 
by  each  practitioner,  as  well  as  their  degree  of  skillfulness  in  the 
application  and  use  of  the  forceps.  Within  a  few  years  past,  in  many  • 
instances  of  pelvic  deformity  in  which  perforation  of  the  head  would, 
previously,  have  been  undertaken,  turning  has  been  successfully 
employed,  and  the  degree  of  measurement  of  the  pelvic  antero- 
posterior  diameter  in  which  craniotomy  may  be  performed,  is  at  this 
day,  placed  at  from  1J  to  2f  inches. 

As  a  general  rule,  where  tjtie  superior  antero-posterior  diameter  of 
the  pelvis  is  contracted  to  about  three  and  a  half  inches,  and  when  the 
forceps  fail  to  extract  the  fetal  head,  this  being  of  usual  size,  the  per- 
forator will  be  required ;  though  it  must  be  remembered,  that  with 
such  a  pelvic  measurement,  there  is  a  possibility  of  extraction  by 
turning,  or,  with  the  forceps.  But  when  the  extent  of  this  small 
diameter  is  reduced,  to  two  and  three-quarter  inches,  the  forceps  can 
usually  be  of  no  avail,  and  craniotomy  will  necessarily  be  required. 
When  the  pelvic  contraction  is  extraordinarily  great,  it  will  be  impos- 
sible to  extract  even  a  mutilated  child,  in  which  case,  the  Cesarean 
operation  is  recommended.  Dewees  considers  the  operation  of  crani- 
otomy inadmissible  where  the  diameter  measures  only  two  inches; 
Baudelocque  limits  it  to  one  and  two-thirds  of  an  inch ;  and  Davis, 
to  one  inch.  The  limit  named  by  Baudelocque  is  probably  the  most 
correct. 


624  KING'S  ECLECTIC  OBSTETRICS. 

Craniotomy  may  be  performed — in  all  cases  of  deformed  pelvis — 
whether  of  the  cavity  or  of  the  straits,  in  which  delivery  can  not  be 
effected  naturally,  by  turning,  or  by  the  forceps ;  in  cases  of  pelvic 
tumors  er  other  abnormal  growths,  which  present  an  obstacle  to  the 
expulsion  of  the  child  by  other  means — either  natural  or  artificial;  in 
cases  of  tedious  and  painful  labor,  when  the  child  is  dead,  and  can  not 
be  removed  by  the  forceps ;  in  cases  of  hydrocephalus,  when  the  head 
can  not  pass  through  the  pelvis ;  in  cases  of  ruptured  uterus,  hemor- 
rhage, convulsions,  etc.,  where  the  life  of  the  woman  is  endangered, 
requiring  immediate  delivery,  and  where  it  is  impossible  to  use  the 
forceps ;  in  cases  where  an  extremity  descends  along  with  the  head, 
causing  an  impaction  which  can  not  be  overcome  by  the  forceps ;  in 
pelvic  labors,  when,  after  the  expulsion  of  the  body,  the  head  can 
not  be  extracted  by  the  forceps ;  in  cases  where  the  head,  remaining 
within  the  pelvis,  has  been  separated  from  the  body ;  and,  in  all  cases, 
where  from  exhaustion,  irregular  vertex  presentations,  or  other  con- 
ditions, the  patient  is  placed  in  imminent  danger,  and  in  which  the 
forceps  can  not  be  applied,  or,  in  which  the  circumstances  of  the  case 
centra-indicate  their  employment,  as  well  as  that  of  version. 

The  practitioner  who  undertakes  the  operation  of  craniotomy,  must 
not  be  too  hasty  in  his  conclusions,  nor  in  his  attempts  at  operating — 
he  must  be  positive  that  it  is  imperatively  necessary,  especially  if  the 
child  be  living — to  destroy  a  living  child,  without  undoubted  evidence 
that  no  other  method  will  save  the  mother's  life,  is  a  criminal  act — it 
is  murder.  When  the  uterine  contractions  have  been  powerful  and 
long  continued,  without  any  advance  of  the  head,  he  will  be  justified 
in  terminating  the  labor  by  the  forceps,  -if  possible,  or  if  not,  by  the 
perforator  and  crotchet.  The  same  may  be  said,  in  cases  where,  from 
exhaustion,  uterine  inertia,  or  other  causes,  endangering  the  mother, 
and  when  there  is  little  or  no  hope  for  the  preservation  of  the  child, 
the  forceps  are  contra-indicated.  Nor  should  the  operator  hesitate  to 
act  at  once,  in  those  cases  where  he  clearly  ascertains  at  an  early  period 
that  the  child  can  not  be  delivered  except  by  craniotomy — as,  for 
instance,  in  an  enormous  hydrocephalic  head,  in  a  small  pelvis,  in  a 
large  head  firmly  ossified,  etc.  To  delay  the  operation  in  these  cases 
until  dangerous  symptoms  manifest  themselves,  would  be  to  unjustly 
compromise  the  mother's  life — while  prompt  action,  when  her  system 
has  not  yet  become  depressed,  and  is  capable  of  more  securely  with- 
standing the  shock  of  the  operation,  will  be  the  wiser  and  more  pru- 
dent course. 

In  cases  requiring  immediate  interference,  at  an  early  period  of 


CRANIOTOMY. 


625 


FIG.  83. 


labor,  the  operation  must  not  be  attempted  until  the  os  uteri  is  suffi- 
ciently dilated  and  fully  dilatable.  In  all  other  cases  we  must  be 
governed  by  the  circumstances  connected  with  them, 
making  endeavors  to  deliver  by  the  forceps  if  there 
is  the  slightest  chance  of  these  being  made  available. 
The  instruments  used  in  the  operation  of  crani- 
otomy  are  the  perforator,  or  Smellie's  perforating 
scissors,  and  the  crotchet.  Professor  Meigs  recom- 
mends the  use  of  a  perforating  trocar  or  drill  (see 
Fiy.  86),  made  especially  for  this  purpose;  by  the 
use  of  this  instrument  we  bore  through  the  skull, 
after  which  the  opening  is  enlarged  by  a  knife  se- 
creted in  the  handle,  and  acted  upon  by  a  spring; 
and,  instead  of  the  crotchet,  he  has  invented  two 

FIG.  85. 
FIG.  84. 


SIMPSON'S  CKANIOCLAST. 

embryotomy  forceps,  one  of 
which  is  straight,  and  the  other 
curved;  each  of  these  are  ser- 
.  rated  on  their  inner  jaws,  to 
enable  them  to  take  a  very  sure 
and  strong  hold  upon  the  cranial 
bones,  and  are  rounded  on  their  SIMPSON' s  PEBFOKATOE.  SMELLIE'S  PERFORATOR. 

sides,  in  order  to  prevent  them  from  taking  hold  of  any  of  the  mater- 
nal tissues.     These  he  considers  superior  to,  and  much  safer  than,  the 
40 


626 


KING'S    ECLECTIC    OBSTETRICS. 


ordinary  perforating  scissors  and  crotchet.  Other  instruments 
have  been  presented  to  the  profession,  as  the  cephalotribe,  crani- 
oclast,  cutting  hook  for  decollation,  or  amputating  limbs,  etc.,  but 
thry  are  rarely  employed,  though  some  of  them  are  very  useful. 
The  cephalotribe  is  for  grasping  and  crushing  the  fetal  head,  includ- 
ing its  base,  and  is  undoubtedly  of  value  in  cases  where  it  becomes 
necessary  to  diminish  the  size  of  the  head.  It  does  not  expose  the 
female  to  the  risks  of  following  the  use  of  the  crotchet,  does  not 


THOMAS'  PERFORATOR. 

require  the  fatiguing  efforts  of  craniotomy,  and  can  be  employed  in 
cases  where  this  operation  could  not  be  successfully  performed.  There 
are  several  varieties  of  this  instrument  before  the  profession,  the  best 
of  which  are  Lusk's  (Fig.  87),  Simpson's,  Hicks',  Kidd's  and  Lazare- 
witch's.  Its  use,  however,  has  not  come  fully  into  practice,  though 
medical  men  are  beginning  to  appreciate  its  usefulness,  under  the  im- 
proved forms  that  have  more  recently  been  given  to  it.  The  crani- 
otomy or  embryotomy  forceps  are  very  useful  in  dislodging  the  head 
after  the  skull  has  been  perforated. 


LUSK'S  CEPHALOTRIBE. 


The  dangers  to  which  craniotomy  exposes  a  female  are,  injury  to 
the  vagina  or  uterus,  from  slipping  of  the  perforator  or  crotchet; 
laceration  of  the  perineum,  from  the  employment  of  improper  extract- 
ing force;  subsequent  tendency  to  inflammation  of  the  vagina  or  uterus ; 
perforation  of  the  bladder,  especially  when  the  operation  has  been 
carelessly  or  too  forcibly  performed;  and  the  shock  to  the  nervous 
system  is  usually  much  greater  than  in  turning,  or  in  the  use  of  the 
forceps.  Instances  have  occurred  where,  from  a  neglect  to  completely 


CRANIOTOMY. 


027 


FIG.  89. 


break  clown   the  brain   and   medulla   oblongata,  the  child  has  been 
born  breathing  and  even  crying. 

MODE  OF  OPERATING.— Previous  to  operating,  the  bladder 
and  rectum  of  the  patient  must  be  thoroughly  evacuated.     Then  she 
must  be  placed  in  the  position  named  for  a  forceps  operation,  with  the 
hips  over  the  edge  of  the  bed,  and  some  cloths  under  her  to  receive 
FIG.  88.  the  pieces  of  brain,  etc.,  which  are 

discharged.  An  assistant  should 
pluee  his  hands  upon  the  abdomen, 
and  maintain  them  there,  during 
the  whole  of  the  operation,  to  fix 
and  steady  the  uterus.  Anaesthesia 
should  be  produced,  if  the  patient 
be  in  a  condition  not  contra-indi- 
cating it;  some  writers  entertain 
objection  to  it,  from  the  fact  that 
extensive  injury  might  be  done  to 
the  maternal  tissues  while  she  lies 
in  an  unconscious  state,  and  no 
timely  warnings  could  be  made,  to 
announce  to  the  operator  when 
the  danger  from  this  circumstance 
commenced ;  no  such  accident,  how- 
ever, is  likely  to  attend  the  manip- 
ulation of  the  careful  operator,  while 
with  its  administration  the  dread 
of  the  operation  is  largely  over- 
come, as  well  as  the  mental  suffer- 
ing and  unpleasant  after-thought. 
Introduce  two  fingers  of  the  left 
hand  within  the  vagina,  and  carry 
them  upward  until  they  come  in  con- 
tact with  the  part  to  be  perforated. 
This  should  be  the  most  depending  portion  of  the  head,  and  a  suture 
or  fontanelle  should  be  avoided,  because  after  the  perforation  is  effected 
in  one  of  these,  the  opening  becomes  closed  from  a  collapse  of  the 
cranial  bones,  which  will  prevent  the  discharge  of  cerebral  matter. 
Then  carry  the  perforator,  which  must  be  warmed  and  greased,  care- 
fully along  the  inside  of  the  fingers,  being  particular  not  to  injure  any 
of  the  parts  of  the  mother,  until  the  sharp  point  comes  in  contact 
(perpendicularly)  with  the  part  selected  for  the  incision. 


SIMPSON'S 

CRANIOTOMY 

FORCEPS. 


628 


KING  S    ECLECTIC    OBSTETRICS. 


FIG.  90.  Still   guarding    the    instru- 

ment from  slipping  or  injur- 
ing the  mother,  press  it  firmly 
but  moderately  against  the 
fetal  skull,  at  the  same  time 
giving  to  it  a  rapid  boring  or 
semi-rotatory  motion ;  a  few 
motions  -will  suffice  to  pierce 
the  bone,  which  may  be 
known  by  the  cessation  of  any 
further  resistance.  (Fig.  90.) 
Then  push  up  the  scissors 
until  the  shoulders  or  rests  at 
the  base  of  each  blade  prevent 
their  further  advance.  Hold- 
ing one  branch  of  the  instru- 
ment firmly,  with  the  thumb 
passed  into  its  eye  or  ring, 
the  fingers  of  the  other  hand 
still '  protecting  the  mother 
from  injury,  by  being  placed 
upon  the  elbows  or  rests  as 
they  move,  to  ascertain  that  they  do  not  leave  the  skull — an  assistant 
will  take  hold  of  the  other  branch,  and  separate  it  from  its  fellow  to 
an  extent  of  three  inches,  and  which  will  cause  the  blades  to  make 
an  incision  about  an  inch  long.  (Fig.  91.) 

Then,  without  withdrawing  the  instrument  from  the  vagina,  turn  it 
round,  and  place  its  point  upon  the  outer  surface  of  the  skull,  so  as  to 
form  another  incision  at  right  angles  with  the  first,  and  crossing  it, 
and  which  is  to  be  done  in  a  similar  and  guarded  manner,  as  before. 
This  having  been  accomplished,  pass  the  blade  through  the  crucial 
incision,  within  the  skull,  and  thoroughly  break  down  the  brain,  by 
alternately  opening  and  shutting  the  blades,  and  turning  them  rapidly 
round  in  various  directions;  and  be  sure  to  cut  across  the  medulla 
oblongata,  so  as  to  completely  destroy  the  life  of  the  child.  The 
scissors  will  now  be  withdrawn,  together  with  the  fingers  covering 
their  cutting  edges. 

If  there  exists  no  necessity  for  immediate  delivery  after  the  destruc- 
tion of  the  brain,  the  operator  may  wait  a  reasonable  time  to  ascertain 
whether  the  natural  powers  will  be  sufficient  to  terminate  it.  But  if 


CRANIOTOMY. 


029 


the  operation  has  been  commenced  after  symptoms  of  exhaustion  or 
other  serious  symptoms  have  manifested  themselves,  he  will  proceed, 
without  delay,  to  finish  the  labor. 

Reintrodueing  the  fingers  of  the  left  hand,  the  crotchet,  having  been 
previously  warmed,  must  be  passed  along  them  into  the  cranium,  and  if 
the  breaking  down  of  the  cerebral  FIG<  m 

mass  was  not  completely  effected  by 
the  scissors,  it  may  now  be  by  the 
crotchet.  After  which,  insert  the 
point  of  the  crotchet  on  the  internal 
surface  of  the  bone,  keeping  a  finger 
of  the  left  hand  upon  the  head  exter- 
nally, and  opposite  to  the  inserted 
point  of  the  instrument,  in  order  to 
cover  it,  and  prevent  injury  to  the 
maternal  parts,  should  it  slip,  or  break 
through  the  bone.  (Fig-  92.)  Pro- 
tecting the  surrounding  parts  from 
injury,  by  folding  the  scalp  over  the 
edges  of  the  bones,  the  practitioner 
will,  by  a  gradual,  steady,  downward 
force,  applied  in  the  direction  of  the 
axis  of  that  part  of  the  pelvic  cavity 
at  which  the  head  may  be  placed, 
commence  the  extraction  of  the  bones. 
He  must  not  pull  by  jerks,  or  he  will 
fracture  the  bones,  and  the  traction 
must  be  made  during  the  pains,  or,  if 
these  are  absent,  they  should  be  im- 
itated by  allowing  intervals  from  time  to  time  during  the  extraction. 
Whenever  the  boue  breaks  under  the  crotchet  point,  this  must  be 
applied  to  some  other  resisting  part  of  the  skull. 

Frequently  the  bones  will  break  and  come  away  by  pieces,  and  then 
great  care  should  be  observed  in  removing  them,  whether  by  the 
fingers  or  the  bone  forceps  made  for  this  purpose.  If  the  head  does 
not  pass  readily,  or  if  a  secure  purchase  can  not  be  made  with  the 
crotchet,  the  craniotomy  forceps  should  be  used ;  or,  if  delay  be  not 
contra-indicated,  the  structures  .will  become  weakened  after  some 
hours,  which  will  render  them  of  more  easy  extraction.  But  I  con- 
sider prompt  delivery,  after  perforation  of  the  skull,  the  better  and 
safer  method  in  all  cases. 


630 


KING'S    ECLECTIC    OBSTETRICS. 


FlG-  92-  If  much  delay  follows  the  perfora- 

tion of  the  skull,  the  crauiotomy 
forceps  should  be  called  into  service 
at  once ;  they  are  to  be  used  by  pass- 
ing one  blade  upon  the  inner  surface, 
and  the  other  upon  the  outer  surface 
of  the  skull,  so  as  to  take  a  firm  and 
secure  hold,  and  then  make  traction 
at  intervals,  the  same  as  with  the 
crotchet.  (Fig.  93.)  After  the  birth 
of  the  head,  it  should  be  covered 
with  a  cloth,  and  if  there  be  a  delay 
in  the  advance  of  the  shoulders,  trac- 
tion may  be  made  upon  the  neck  in 
the  direction  of  the  axis  of  the  brim, 
or  a  blunt  hook  may  be  passed  under 
one  or  each  axilla,  to  facilitate  their 
expulsion.  Sometimes  the  trunk 
will  not  advance,  when  it  will  be- 
cdme  necessary  to  perforate  the  chest 

and  remove  its  contents,  as  well  as  those  of  the  abdominal  cavity, 
extracting  the  ribs  by  the  crotchet,  somewhat  similar  to  the  removal 
of  the  cranial  bones. 

In  case  of  a  separation  of  the  head 
from  the  body,  the  latter  being  delivered, 
the  forceps  will  require  to  be  applied  in 
order  that  the  head  may  be  held  firmly, 
while  the  perforator  is  being  used  to  re- 
duce its  size. 

After  the  operation,  keep  the  patient 
quiet,  overcoming  the  nervous  shock  by 
the  continuation  of  the  anaesthetic,  or 
after  a  reasonable  time  a  quarter-grain  of 
Morphia  may  be  administered,  or  a  five- 
grain  dose  of  the  compound  powder  of 
Ipecacuanha  and  Opium,  or  some  similar 
preparation,  and  the  vagina  may  be  oc- 
casionally cleansed  by  injections  of  warm 
water.  Should  symptoms  of  inflamma- 
tion set  in,  promptly  remove  them  by  the 
proper  measures. 


FIG.  93. 


CESAREAN    OPERATION.  631 

CESAKEA.N  OPERATION.  The  Cesarean  section,  or  hysterot- 
oiny,  is  a  less  favorable  operation  to  the  mother  than  either  of  the 
preceding,  and,  consequently,  is  never  to  be  attempted  for  the  purpose 
of  delivering  the  child,  except  as  a  last  resource.  Though  a  simple 
operation,  it  is  exceedingly  dangerous,  and  should  never  be  under- 
taken except  upon  justifiable  grounds.  According  to  statistics — which 
are  hardly  reliable,  from  the  fact  that  the  cases  reported  are  generally 
the  successful  ones,  a  number  of  the  unsuccessful  being  suppressed — 
about  one  mother  in  two  and  one-third  is  saved,  and  about  one  child 
in  three  and  one-third. 

The  operation  is  resorted  to  with  a  view  of  effecting  delivery  with 
safety  to  the  mother  and  her  offspring,  in  those  cases,  where  it  is 
impossible  to  deliver  through  the  natural  passages,  either  by  the 
forceps  or  perforator.  In  a  pelvis  whose  superior  antero-posterior 
diameter  does  not  exceed  one  and  a  half  inches,  it  will  be  almost,  if 
not  quite  impossible,  to  extract  even  a  mutilated  child,  without 
powerful  efforts,  exposing  the  mother  thereby,  to  at  least  as  serious 
results,  as  would  be  likely  to  follow  this  section.  And  in  such  cases 
the  operation  will  be  required  whether  the  child  be  alive  or  not. 
Mollities  ossium,  or  the  presence  of  tumors  or  other  abnormal  growths 
within  the  pelvis,  reducing  its  diameters,  and  preventing  the  advance 
of  the  child;  may  render  a  resort  to  this  operation  necessary,  especially 
when  they  can  not  be  removed  or  lessened  in  size,  by  other  means,, 
heretofore  referred  to. 

When  the  mother  has  died  suddenly  during  labor,  the  child  being 
still  alive,  the  Cesarean  operation  has  frequently  been  the  means  of 
saving  it;  and  in  order  to  afford  it  every  opportunity  of  being  saved, 
the  operation  should  be  performed  as  promptly  as  possible.  Cases 
are  cited  in  which  the  living  child  has  been  delivered  in  this  manner 
in  from  ten  to  fifteen  minutes  after  the  death  of  the  mother. 

The  dangers  to  which  the  Cesarean  section  exposes  the  female  are, 
hemorrhage,  both  from  the  uterine  and  abdominal  blood-vessels, 
though  fatality  from  this  cause  occurs  less  frequently  than  was  for- 
merly supposed;  subsequent  inflammation  of  the  uterus,  or  peritonitis; 
death  from  the  shock  to  the  nervous  system;  and,  strangulation  of  a 
portion  of  the  intestines,  which  may  be  held  between  the  lips  of  the 
external  incision,  or  that  made  in  the  uterus. 

The  earlier  the  operation  is  performed,  the  more  favorable  will  it 
be  for  the  mother,  because  her  strength  will  be  less  impaired  than 
after  a  prolonged  uterine  action;  and  in  cases  where  it  is  positively 
known  that  the  operation  must  be  performed  before  delivery  can  be 


632  KING'S  ECLECTIC  OBSTETRICS. 

effected,  it  should  be  undertaken  at  the  commencement  of  labor.  The 
period  named  by  authors  as  the  most  favorable  for  operating,  is  after 
full  dilatation  of  the  uterus  and  before  the  rupture  of  the  membranes, 
and  the  longer  the  operation  is  delayed  after  this  has  taken  place,  the 
more  unfavorable  will  it  be  for  the  mother. 

Several  cautions  are  given,  by  those  who  have  performed  the  opera- 
tion, which  it  is  necessary  to  be  mindful  of;  according  to  Ramsbotham, 
these  are :  1st,  to  avoid  dividing  the  tendinous  expansion  of  the  recti 
muscles  forming  the  linea  alba,  because  from  its  low  degree  of  organ- 
ization it  would  not  be  so  apt  to  heal  as  kindly  as  the  must-le  itself; 
2d,  to  avoid  making  the  incision  so  far  toward  the  side  as  to  run  the 
risk  of  wounding  the  epigastric  artery;  3d,  to  expose  the  naked  surface 
of  the  uterus  no  longer  than  is  absolutely  required,  being  especially 
careful  to  handle  the  organ  as  little  as  possible ;  4th,  to  avoid  making 
the  incision  at  the  side  of  the  uterus,  or  at  that  part  of  the  organ  to 
which  the  placenta  is  attached,  on  account  of  its  being  the  most  vascu- 
lar part,  and  which  may  be  ascertained  by  the  stethoscope ;  5th,  to 
avoid  wounding  the  child  when  incising  the  uterus;  6th,  not  to  allow 
much  time  to  elapse  between  the  extraction  of  the  child  and  that  of 
the  placenta;  7th,  be  especially  careful  that  none  of  the  intestines 
become  included  with  the  lips  of  either  incision,  as  the  risks  of  strangu- 
lation would  be  added  to  those  of  the  operation. 

Recent  reports  indicate  that  nearly  seven  thousand  children  are 
sacrificed  annually  in  the  United  States  by  embryotomy;  this  fact, 
together  with  the  progress  and  improvement  of  modern  surgical 
operations,  has  inclined  many  of  the  best  known  surgical  obstetricians 
to  seek  ways  and  means  to  overcome  this  terrible  destruction  of 
human  life.  Premature  delivery  and  abdominal  section  are  the  only 
alternatives  to  be  considered.  It  is  now  claimed,  by  several  of  the 
most  prominent  writers  on  the  subject,  that  in  view  of  the  diminished 
death  rate  following  the  improved  Sanger-Cesarean  operation,  crani- 
otorny  upon  the  living  child  is  never  justifiable.  That  the  child's 
interests  are  deserving  of  some  consideration  along  with  those  of  the 
mother  there  can  be  no  doubt,  in  cases"  where  the  disproportion 
between  the  head  and  pelvis  will  not  admit  of  natural  delivery ;  but 
I  can  not  concur  in  the  belief  that  relief  should  always  be  sought  in 
abdominal  section,  or,  in  other  words,  that  craniotomy,  under  such 
circumstances,  is  never  justifiable.  The  condition  of  the  mother 
should  always  govern  our  action  in  such  cases;  owing  to  this  fact, 
the  means  of  relief  can  not  be  looked  upon  as' operations  of  election. 


CESAREAN    OPERATION. 


633 


In  correspondence  with  Prof.  William  H.  Watheu,  of  Louisville,  an 
able  supporter  of  abdominal  section,  I  have  been  able  to  glean  the 
following  from  an  article  recently  written  by  him.  The  results  of  both 
the  Sanger-Cesarean  and  Porro-Cesarean  are  given,  as  well  as  the 
indications  for  each.  He  refers  me  to  a  recent  contribution  to  the 
American  Journal  of  Obstetrics,  in  which,  after  considering  the  subject 
of  Craniotomy,  he  goes  on  to  say  : 

"Let  us  now  briefly  consider  the  results  to  mother  and  child  where 
the  alternatives  [to  craniotomy]  have  been  adopted.  We  will  not 
waste  time  considering  the  old  statistics  of  Cesarean  section,  where 
the  operation  was  performed  crudely,  with  none  of  the  modern  or 
more  successful  modifications,  and  generally  only  as  a  Vernier  resort, 
for  in  such  cases  it  is  not  possible  to  get  good  results.  Xor  will  we 
consider  the  results  of  laparo-elytrotomy ;  for  this  operation  is  too 
complicated  for  general  adoption,  and  in  the  practice  of  expert 
operators  has  not  given  as  good  results  as  the  improved  Cesarean 
section  or  Porro's  operation.  Xor  is  it  hardly  fair  to  include  the 
statistics  of  the  improved  Cesarean  section  or  Porro's  operation  in  the 
United  States,  for  nearly  all  these  operations  have  been  done  after 
exhausting  all  other  means,  with  the  women  nearly  dead,  and  seldom 
as  operations  of  election. 

"The  following  are  the  most  complete  statistics  available  on  the 
improved  Cesarean  section,  Porro's  operation,  and  the  induction  of 
premature  labor,  for  which  I  am  largely  indebted  to  the  courtesy  of 
Dr.  R.  P.  Harris,  of  Philadelphia : 

PORRO-CESAREAN  OPERATIONS. 


No. 

Countries. 

Operators. 

Localities. 

Cases. 

Women 
Saved. 

Women 
Lost. 

1 

Italy  

52 

35 

92 

48 

44 

2 

Austria  

15 

7 

61 

43 

18 

3 

Germany  

27 

18 

43 

99 

->1 

4 

France  

9 

17 

6 

11 

5 

England   

10 

t) 

12 

5 

7 

6 

Russia         

G 

4 

10 

7 

United  State?     

9 

9 

9 

8 

Belgium                 

4 

., 

5 

3 

9 

9 

Scotland  

4 

9 

5 

1 

4 

10 

Switzerland  

9 

9 

4 

3 

1 

11 

Holland  

9 

9 

9 

1 

1 

12 

Australia  

9 

9 

9 

9 

0 

13 

Spain   ^  

1 

1 

1 

0 

1 

14 

Mexico  *.  

1 

1 

1 

o 

1 

15 

Japan  

1 

1 

1 

1 

0 

265 

144 

121 

634 


KING'S    ECLECTIC    OBSTETRICS. 
SANGER-CESAREAX  OPERATION. 


N,-. 

Countries. 

Operators. 

Localities. 

Cases. 

W071H'I1 

Saved. 

Women 
Lost. 

•     1 

Germany     

44 

00 

92 

79 

0 

Austria  

13 

7 

:;•_' 

28 

6 

3 

United  States  

24 

13 

32 

15 

17 

4    ' 

Russia  

7 

5 

10 

3 

5 

Holland  

5 

5 

9 

9 

o 

<; 

Italy   . 

3 

3 

7 

5 

•> 

France  

9 

1 

4 

2 

.> 

8 

England  

3 

9 

3 

1 

9 

9 

India     

1 

1 

>> 

1 

1 

10 

Switzerland  

2. 

1 

n 

1 

1 

11 

Denmark  

1 

1 

1 

.      l 

o 

194' 

147 

47 

"It  will  thus  be  seen  that  Porro's  operation  has  saved,  in  all 
countries,  54.33  per  cent,  of  the  mothers,  and  82.77  per  cent,  of  all 
children,  or  137.10  lives  out  of  200  involved,  while  the  improved 
Cesarean  section  has  saved  75.77  per  cent,  of  the  mothers,  and  93  81 
per  cent,  of  the  children,  or  out  of  a  total  of  200  lives  has  saved 
169.58  lives.  But  if  we  properly  exclude  the  improved  Cesarean 
operations  in  the  United  States,  81.48  per  cent,  of  all  the  mothers 
were  saved;  thus  saving,  out  of  200  lives,  175.29  lives.  The  above 
is  conclusive  that  Porro's  operation  can  not  be  substituted,  only  in 
exceptional  cases,  for  Cesarean  section,  unless  future  results  materially 
change  the  statistics." 

In  closing  the  article,  Dr.  Wathen  speaks  of  the  conditions  in 
which  the  Pdrro  operation  should  be  preferred,-  I  quote  his  words  as 
follows:  "That  the  Porro  operation  is  preferable  to  the  Cesarean 
section,  in  some  cases,  no  one  will  deny,  and  Sanger  gives  the  follow- 
ing indications  for  its  performance: 

"  1.  When  the  discharge  of  lochial  secretions  is  rendered  difficult  or 
impossible  per  vias  naturales — i.  e.,  by  stenoses  and  artesise  of  the  cer- 
vix and  vagina,  or  by  tortuosity  and  compression  of  the  soft  obstetric 
canal  due  to  a  tumor  not  belonging  to  the  uterus. 

"  2.  By  pregnancy  in  the  closed-up  half  of  a  uterus-bicornis,  in 
which  delivery  is  preferably  effected  by  establishing  an  artificial 
opening  toward  the  open  half  (strictly  speaking,  this  is  not  a  true 
Porro  operation,  since  the  remaining  half  of  tke  uterus  may  be  again 
impregnated). 

"3.  When  the  infection  of  the  corpus  uteri  is  evident. 


CESAREAN    OPERATION.  635 

"4.  After  repeated  classical  sectio  Csesaria. 

"  5.  By  serious  osteomalacia. 

"When  delivery  per  vias  naturales  is  prevented  by  uterine  or 
abdominal  tumors,  the  alternative  to  craniotomy  is  to  remove  the 
tumors,  if  it  is  possible  to  do  so,  otherwise  the  Porro  operation  is  the 
proper  alternative.  Porro's  operation  is  also  indicated  in  a  ruptured 
uterus,  where  the  rent  extends  through  all  the  coats,  whether  the 
child  is  in  the  abdominal  cavity,  the  uterus,  or  has  been  delivered. 
If  the  blood,  the  bloody  serum,  and  liquor  amnii  be  thoroughly 
removed  from  the  peritoneal  cavity  before  decomposition  or  inflam- 
mation, the  operation  offers  but  few  additional  dangers  and  removes 
many.  But  the  operation  should  be  done  immediately,  for  all  the 
pathological  changes  are  against  the  late  operation.  The  woman  may 
have  recovered  from  the  shock,  but  adventitious  sacs,  plastic  adhe- 
sions, etc.,  will  have  formed,  will  prove  troublesome,  and  will  prevent 
success. 

MODE  OF  OPERATING.  — Having  previously  emptied  the 
bladder  and  rectum,  the  female  is  to  be  placed  upon  her  back,  with 
her  shoulders  and  head  elevated  by  pillows;  she  may  be  in  bed,  or 
upon  a  table  with  a  mattress  on  it,  and  may  lie  lengthwise,  or  with 
her  hips  brought  to  the  edge  of  the  bed,  the  feet  hanging  down 
toward  the  floor.  A  table  is  always  preferable,  and  can  be  easily  im- 
provised by  preparing  the  common  table,  found  in  every  house,  and 
covering  it  with  blankets  and  comforters,  as  need  be,  to  make  it  com- 
fortable. Ramsbotham  advises  the  temperature  of  the  room  to  be 
brought  to  at  least  80°  Fahrenheit,  and  properly  disinfected;  sulphur- 
ous acid  gas,  generated  by  burning  sulphur,  answers  every  purpose. 
In  order  to  avoid  injury  to  any  of  the  uterine  appendages,  the  uterus 
must  be  brought  in  the  median  line,  and  kept  there  by  the  hands  of 
an  assistant  being  placed  over  it;  and  to  prevent  any  part  of  the 
intestines  from  insinuating  themselves  between  the  uterine  and 
abdominal  walls,  a  second  assistant  may  make  pressure  with  one  hand 
over  the  uterine  fuudus.  Anaesthesia  is  undoubtedly  of  great  value 
in  performing  this  operation.  Ether  is  preferred  by  some  operators; 
Chloroform,  however,  is  less  likely  to  produce  nausea,  vomiting  and 
retching,  greatly  embarrassing  the  operator..  A  mixture  of  the  two 
agents  is  sometimes  used.  A  profound  state  of  anaesthesia,  however, 
should  be  induced,  regardless  of  the  agent  used. 

An  incision  of  about  six  inches  in  length  is  now  to  be  made  through 
the  abdominal  walls,  extending  from  a  short  distance  below  the  um- 


636  KING'S  ECLECTIC  OBSTETRICS. 

bilious,  to  within  about  two  inches  of  the  pubes,  as  a  further  extension 
of  it  would  endanger  the  bladder.  The  abdomen  should  be  carefully 
washed  with  an  antiseptic  solution;  carbolized  water  answers  a  very 
good  purpose.  The  incision  should  now  be  made,  from  the  umbilicus 
downward  in  the  median  line.  The  parts  should  be  carefully  divided, 
layer  by  layer,  as  far  as  the  peritoneum,  into  which  a  small  aperture 
is  to  be  cautiously  made,  sufficiently  large  to  admit  the  introduction 
of  the  index  finger  of  the  left  hand  (or  a  grooved  director)  as  a 
director  for  a  probe-pointed  bistoury,  and  to  prevent  it  from  wound- 
ing the  intestines.  Tho  peritoneum  must  be  divided  until  the  incision 
is  of  the  same  dimensions  with  that  of  the  integuments  above,  when 
the  uterus  will  be  brought  into  view.  An  incision  of  about  five  or 
six  inches  in  length  is  now  to  be  made  into  the  body  only  of  the 
uterus,  carefully  dividing  layer  after  layer,  until  the  placenta,  or  the 
membranes  are  brought  into  view,  and  which  latter  may  be  known  by 
their  transparency.  Make  a  slight  opening  into  the  membranes,  if 
these  have  not  been  ruptured  previously,  and  by  means  of  pieces  of  soft 
sponge  remove  some  of  the  liquor  •amnii,  or  it  may  be  more  quickly 
removed  by  a  proper  syringe.  Then  enlarge  the  orifice  in  the  mem- 
branes, withdraw  the  child,  seizing  it  by  the  lower  extremities,  tie  the 
cord,  and  extract  the  placenta  and  membranes,  having  first  twisted 
them  into  a  cord.  Should  the  placenta,  however,  present  first,  it 
must  not  be  divided,  but  detached  at  one  side,  that  the  membranes 
may  be  reached. 

When  the  membranes  are  ruptured,  the  assistants  must  be  careful, 
in  holding  the  lips  of  the  wound  apart,  that  the  abdominal  and  uter- 
ine walls  are  kept  in  contact  with  each  other,  that  none  of  the  amni- 
otic  liquid  may  pass  between  them  into  the  abdominal  cavity.  After 
the  removal  of  the  child,  the  uterus  commonly  contracts  and  detaches 
the  placenta;  but  if  this  be  not  effected ,  it  must  be  accomplished  arti- 
ficially, by  making  traction  on  the  cord,  and  peeling  off  with  the 
fingers.  The  operator  must  also  ascertain  that  the  canal  of  the  cervix 
is  free,  in  order  that  the  lochia  may  escape,  and  this  may  be  learned 
by  passing  a  finger  through  the  os  uteri  from  the  wound,  and  one  or 
two  of  the  other  hand  per  vaginam.  In  the  event  of  permanent 
obstruction,  characterized  by  marked  stenosis,  it  is  suggested  the 
Porro  operation  be  selected. 

Any  blood  or  other  foreign  body  which  may  have  passed  within 
the  uterine  cavity,  must  be  removed,  and  the  wound  in  the  organ 
must  be  well  cleansed.  The  contraction  of  the  uterus  generally  brings 


CESAREAN    OPERATION.  637 

the  lips  of  the  wound  in  contact,  so  that  there  will  be  but  little 
hemorrhage.  It  is  well,  however,  in  the  beginning,  to  throw  a  tem- 
porary rubber  ligature  about  the  lower  uterine  segment,  to  be  tight- 
ened in  case  of  emergency.  After  cleansing  the  borders  of  the  uterine 
incision,  the  wound  should  be  closed  with  sutures. 

The  great  mortality  in  this  operation  heretofore  has,  no  doubt,  been 
largely  due  to  the  inability  to  properly  close  the  uterine  incision. 
The  modification  of  Sanger  has  done  much  to  overcome  this  defect, 
and  in  order  to  clearly  define  the  Sanger- Cesarean  operation,  I  quote 
the  following  from  Lusk,  page  430  of  his  work  on  Midwifery: 

"  It  is  obvious  that  the  classical  Cesarean  section,  even  with  the 
addition  of  the  suture  and  the  employment  of  strict  antisepsis,  is  still 
far  from  answering  the  requirements  of  a  conservative  procedure.  To 
place  it  upon  the  same  plane  with  other  forms  of  abdominal  surgery, 
it  is  necessary  to  devise  some  means  to  surely  prevent  the  separation 
of  the  uterine  wound,  which  has  been  found  to  occur  in  spite  of  the 
suture  and  the  most  careful  coaptation  of  the  cut  surfaces.  The  sec- 
ondary gaping  is  due,  in  a  measure,  to  the  tendency  of  the  external 
borders  of  the  wound  to  become  everted  after  section,  the  wound,  in 
consequence,  assuming  u  prismatic  shape,  but  chiefly  to  the  alternating 
periods  of  contraction  and  relaxation  in  the  uterine  muscle  itself, 
whereby  the  tension  of  the  sutures  is  subjected  to  a  continual  change. 
Recently  both  Kehrer  and  Sanger  have  proposed  modifications  in  the 
methods  of  operating,  designed  to  render  more  certain  the  speedy 
union  of  the  tissues  along  the  lifle  of  the  incision. 

"  Sanger,  after  an  exhaustive  study  of  the  past  history  of  the 
uterine  suture  as  employed  in  cases  of  Cesarean  section,  concludes 
that  the  prevention  of  the  escape  of  the  lochia  from  the  uterus  into 
the  abdominal  cavity  subsequent  to  the  operation  is  best  secured  by 
the  employment  of  special  means  for  bringing  the  peritoneal  surfaces 
into  immediate  contact  with  one  another,  as  it  is  a  fact,  made  familiar 
by  Sir  Spencer  Wells,  that  two  peritoneal  surfaces  in  apposition  unite 
within  twenty-four  hours.  In  order  to  attain  this  end,  Sanger  sug- 
gested that,  after  the  removal  of  the  child  through  the  ordinary 
incision,  and  a  temporary  elastic  ligature  had  been  placed  around  the 
cervix,  a  narrow  strip  of  muscular  tissue  should  be  removed  by  a  sec- 
tion running  at  first  parallel  to  the  borders  of  the  wound,  but  diverg- 
ing outward  as  the  section  approached  the  peritoneal  surface. 

"  The  peritoneum  was  next  to  be  detached,  and  allowed  to  cover 
the  expanded  portion  of  the  Y-shaped  section.  He  then  advised  the 
introduction  of  deep  uterine  sutures,  running  obliquely  through  the 


638  KING'S  ECLECTIC  OBSTETRICS. 

uterine  tissues  to  the  inner  borders  of  the  wound,  avoiding,  however, 
the  decidua,  with  a  second  set  of  superficial  sutures,  designed  to  secure 
the  contact  of  the  peritoneal  borders.  The  principle  of  subpcritoueal 
muscular  resection,  as  Sanger  termed  his  method,  has  been  tested  in 
three  instances  by  Lepold,  with  the  saving  of  the  three  mother-  as 
well  as  the  three  children.  In  practice,  however,  the  plan  was  found 
to  require  some  modification.  Thus  Lepold,  after  raising  the  peri- 
toneum with  tissue  forceps  from  the  borders  of  the  wound,  separated 
it  by  a  horizontal  incision,  made  with  a  bistoury,  to  the  extent  of  a 
half  centimeter  at  the  upper  and  lower  angles,  and  about  one  centi- 
meter at  the  middle  of  the  wound.  In  carrying  out  this  dissection,  a 
layer  of  muscular  tissue,  upward  of  a  millimeter  in  thickness,  was 
removed  with  the  peritoneum.  Then,  after  lifting  the  detached  serous 
layer,  he  removed,  cutting  from  within  outward,  from  each  side  a 
segment  of  muscular  tissue  extending  through  the  entire  thickne.-.-  of 
the  uterine  walls — each  segment  possessing  a  wedge-shape,  with  the 
base  above  and  the  apex  directed  toward  the  decidua.  In  this  way  he 
obtained  two  smooth  muscular  surfaces  overlapped  by  a  wide  layer  of 
serous  membrane.  The  deep  sutures  employed  were  of  silver,  while 
the  superficial  ones  were  in  one  case  composed'  of  catgut,  in  the 
two  others  of  fine  silk." 

Should  any  blood  have  escaped  into  the  abdominal  cavity,  remove 
it  by  lightly  sponging;  and,  while  an  assistant  retains  the  intestines 
in  their  place,  close  the  wound  in  the  abdomen  by  as  many  silver 
wire  sutures  as  may  be  necessary,  leaving  a  space  at  the  lower  part  for 
the  exit  of  the  fluids  which  escape  from  the  abdomen.*  Between  and 
over  the  sutures,  strips  of  adhesive  plaster  should  be  applied,  over 
which  may  be  placed  a  number  of  layers  of  antiseptic  gauze,  the  whole 
being  kept  in  position  by  a  bandage  drawn  moderately  tight.  During 
the  operation  care  must  be  taken  not  to  permit  the  intestines  to 
extrude,  and  to  keep  them  warm  and  moist  by  means  of  hot  flannels 
applied  from  time  to  time  upon  the  abdomen. 

Blundell  suggests  the  propriety  of  rendering  the  Fallopian  tubes 
impervious,  by  removing  a  small  portion  of  their  substance  on  each 
side,  during  the  operation,  thereby  preventing  the  possibility  of  con- 
ception, without  destroying  the  sexual  appetite. 

*  It  has  been  "ad vised  to  include  the  peritoneum  in  the  sutures,  so  that  the  inner 
part  of  the  wound  will  have  the  peritoneal  surfaces  in  contact,  and  not  to  leave  an 
opening  for  the  exit  of  the  fluids,  thereby  favoring  a  speedy  union;  the  same  as  when 
treating  a  simple  incised  wound. 


CESAREAX    OPERATION.  639 

After  the  operation,  the  condition  of  the  patient  may  render  the 
administration  of  stimulants  necessary.  When  she  has  been  placed  in 
bed,  administer  an  opiate,  and  treat  the  case  on  general  principles  to 
lessen  irritability,  and  prevent  or  allay  any  febrile  or  inflammatory 
symptoms  which  may  come  on,  treating  them  promptly  and  ener- 
getically. The  patient  must  be  kept  quiet,  visitors  must  be  excluded 
from  the  room,  which  should  be  kept  rather  cool,  and  any  inflamma- 
tion along  the  ed^es  of  the  incision  must  be  at  once-  reduced  by  cold 
water,  or  fomentations,  as  seems  best  suited  to  the  case.  Small  doses 
of  tincture  of  Aconite,  with  or  without  tincture  of  Gelsemium,  will 
aid  considerably  in  averting  inflammation.  The  diet  must  be  exceed- 
ingly light,  and  the  utmost  care  and  attention  should  be  bestowed 
upon  the  female  The  catheter  should  be  passed  until  the  patient  is 
able  to  pass  her  urine  without  straining;  likewise,  the  bowels  should 
be  held  in  check  for  several  days.  The  child  should  be  fed  until  the 
mother  is  beyond  danger,  and  in  the  meantime  the  milk,  should  any 
be  present,  may  be  removed  by  a  young  puppy,  or  by  a  pump  made 
for  this  purpose. 

It  is  always  proper  to  have  \varm  water  on  hand,  in  order  to  place 
the  child  in  it,  should  animation  be  suspended. 

The  PORRO  OPERATION.— The  Porro- Cesarean  section  con- 
sists in  amputating  and  removing  the  uterus,  after  the  delivery  of  the 
child,  through  the  abdominal  section.  The  indications  for  the  opera- 
tion, as  well  as  the  statistics  relating  thereto,  have  been  given  in  the 
preceding  section.  The  body  of  the  organ  should  be  dragged  through 
the  abdominal  incision,  and  the  child  delivered  as  in  the  Cesarean 
section ;  an  elastic  cord,  encircling  the  cervix,  should  be  tightened,  to 
prevent  hemorrhage.  The  uterus  is  held  in  the  abdominal  incision  by 
a  couple  of  knitting  needles,  and  is  then  amputated,  including  the 
tubes  and  ovaries.  For  a  full  account  of  this  operation,  the  reader  is 
referred  to  Prof.  Howe's  excellent  work  on  Operative  Gynaecology, 
page  187. 

The  operation  of  SYMPHYSEOTOMY,  or  an  artificial  separation 
of  the  pubic  bones  at  their  symphysis,  has  been  advised  in  cases  of 
excessive  deformity  of  the  pelvis ;  but  as  I  can  not  conceive  of  a  case 
in  which  it  would  be  justifiable,  being  attended  with  many  dangers,  I 
shall  not  enter  into  any  description  of  it. 

LAPARO-ELYTROTOMY.— This  is  another  of  the  operations 
advised,  where  natural  delivery  is  impossible;  it  has,  however,  only 


640  KING'S  ECLECTIC  OBSTETRICS. 

been  executed  a  few  times.  The  advantage  claimed  for  it  over 
abdominal  section  was  that  the  opening  of  the  cavity  of  the  peri- 
toneum could  be  avoided,  as  well  as  incising  the  uterus.  The  opera- 
tion consists  in  an  incision  from  the  pubic  symphysis,  along  the  line 
of  Poupart's  ligament  to  the  ilium,  through  the  walls  of  the  abdo- 
men to  the  upper  part  of  the  vagina,  which  is  opened.  The  os  and 
cervix,  already  dilated,  are  directed  into  the  wound,  and  the  child 
extracted  therefrom.  When  the  peritoneum  is  reached,  it  is  pushed 
away  from  the  line  of  the  incision  by  raising  it. 

A  necessity  for  the  operations  above  named  may  frequently  be 
obviated,  where  the  pelvic  measurements  are  known  to  be  too  small, 
by  the  induction  of  premature  delivery,  or  even,  in  some  cases,  of 
abortion. 


CHAPTER   XLVII. 

INDUCTION"   OF    PREMATURE    LABOR. 

IN  cases  where  it  is  known  that  the  fetus,  at  full  term,  would  be 
unable  to  pass  through  the  pelvis,  either  naturally  or  by  the  aid  of 
forceps,  owing  to  a  deformed  condition  of  the  pelvic  bones,  the 
INDUCTION  OF  PREMATURE  LABOR  is  recommended;  an 
operation  which  has  for  its  object  the  safety  both  of  the  mother  affd 
her  child.  This  operation  originated  in  England,  where  it  has  been 
practiced  since  1756,  at  which  time,  we  are  told  by  Denman,  a  consul- 
tation of  most  eminent  practitioners  in  London  was  held  to  determine 
the  question  of  its  morality,  safety,  and  utility;  which  having  been 
decided  affirmatively,  the  operation  was  first  successfully  performed 
by  Dr.  Macaulay.  Frbm  England  it  was  carried  into  Germany,  in 
1799,  by  A.  Mai,  but  was  not  practiced  until  in  1804,  by  Wenzel.  In 
France  it  was  not  performed  until  1831,  by  Stoltz,  having  previously 
met  with  much  opposition  as  an  immoral  and  criminal  procedure.  At 
this  time,  however,  it  is  considered  by  all  obstetricians  as  a  perfectly 
justifiable  operation. 

The  induction  of  premature  labor  consists  in  exciting  the  uterus  to 
contract,  leaving  the  subsequent  expulsion  to  the  natural  efforts ;  con- 
sequently, it  differs  from  a  "forced  delivery,"  in  which  nearly  the 
whole  process  is  conducted  bv  artificial  means.  It  is  not  to  be 


INDUCTION    OF    PREMATURE    LABOR.  641 

attempted  until  at  the  period  of  fetal  viability,  or  during  the  seventh 
or  eighth  months.  Its  intention  is  to  safely  deliver  the  living  child, 
instead  of  waiting  for  the  natural  term,  to  destroy  it  by  the  perforator, 
and  thus  expose  the  mother  to  much  risk;  and,  also,  to  save  the 
mother  from  the  hazardous  Cesarean  operation. 

It  has  been  objected,  that  it  is  impossible  to  accurately  determine 
the  relative  proportions  existing  between  the  fetal  head  and  the  female 
pelvis.  This  is  a  very  trifling  objection,  and  one  that  should  bear  no 
weight  at  all  in  the  consideration  of  the  question  of  operating;  because 
these  points  may  be  determined  with  sufficient  accuracy  for  all  practical 
purposes,  by  the  various  methods  heretofore  explained  ;  and  should 
we,  even,  arrive  at  a  wrong  estimate  in  these  measurements,  it  would 
be  of  no  great  importance ;  I  consider  the  following  reasons,  given  by 
Velpeau,  as  correct,  and  of  much  value — he  says:  "If  the  pelvis  be 
wider  than  we  thought,  premature  delivery  (at  or  after  the  seventh 
month)  is  accomplished  without  risk.  If,  on  the  contrary,  the  nar- 
rowing be  more  considerable,  the  fetus  will  certainly  perish;  but  then, 
had  no  operation  been  attempted  till  the  full  term,  the  fetus  would 
equally  have  been  lost,  and  the  mother  would  have  run  greater  risk." 

But  whatever  may  be  the  objections  raised  against  this  operation,  it 
must  always  be  borne  in  mind  that  the  results  are  not  so  serious  to 
either  mother  or  child,  as  when  pregnancy  is  permitted  to  proceed  to 
its  full  period.  Thus,  where  craniotomy  is  performed,  not  only  are  the 
infants  destroyed,  but  one  in  five  mothers  are  lost;  where  the  Cesarean 
operation  is  achieved,  the  children  die  in  the  proportion  of  one  in 
three  and  a  half,  and  the  mothers  of  one  in  two  and  one-third.  Where 
premature  labor  is  effected,  more  than  half  of  the  children  are  saved, 
while  only  one  mother  in  sixteen,  is  lost.  In  161  cases  of  premature 
delivery,  given  by  Velpeau,  eight  died,  five  of  which  perished  from 
causes  not  connected  with  parturition;  in  280  cases,  given  by  Figueira, 
only  six  were  lost.  Here,  then,  are  441  cases  of  premature  delivery, 
of  which  only  nine  died,  or  about  one  in  fifty.  What  sane  man  can, 
with  these  results  before  him,  morally  or  religiously  object  to  an  opera- 
tion so  "highly  favorable  to  both  mother  and  child?  Prof.  William 
Wathen  calls  attention  to  Maygrier,  who  gives  the  following  statis- 
tics in  induced  labor  in  pelves  of  2.73  inches :  "  Mothers  saved,  66.67 
per  cent.;  children  saved,  35.30  per  cent. — 101.97  lives  saved  out  of 
200."  These  are  the  best  results  that  have  been  obtained,  and  the 
percentage  of  lives  saved' might  be  materially  lowered  by  deducting 
those  children  that  died  within  a  few  days  or  weeks  after  birth. 
41  ,,'. 


642 


KINGS    ECLECTIC   OBSTETRICS. 


The  induction  of  premature  labor,  in  cases  of  malformed  pelvis,  is  to 
be  effected  only  when  the  small  diameter  of  the  superior  strait  ranges 
between  two  and  a  half  and  three  inches;  under  which  circumstances  it 
would  be  impossible  for  the  full  developed  fetal  head  to  pass  naturally, 
or  even  with  the  aid  of  the  forceps.  At  seven  months,  according  to 
the  researches  of  several  eminent  obstetricians,  the  bi-parietal  diameter 
of  the  fetal  head  is  from  two  and  a  half  to  two  and  three-quarter  inches, 
or  not  quite  three  inches,  and  consequently  it  may  pass  very  readily 
through  a  pelvis  the  smallest  diameter  of  which  is  contracted  to  a 
measurement  between  two  and  a  half  and  three  inches:  a  smaller 
pelvic  diameter  than  this  would  render  the  passage  of  the  fetal  head 
impossible  even  at  the  seventh  month,  unless  it  should  be  a  very  small 
one;  but  as  we  have  no  means  of  determining  this  while  the  fetus  is 
yet  within  the  uterus,  the  practitioner  is  necessarily  bound  to  govern 
himself  by  the  standard  measurement  as  given.  The  following  ap- 
proximate measurements  of  the  fetal  head  have  been  given  by  M. 
Figueira,  and  will  undoubtedly  be  of  some  utility  to  the  practitioner: 


Age  of  the  Fetus. 

Bi-parietal 
Diameter. 

Occi  pi  to-frontal 
Diameter. 

Occipito-bregmatic 
Diameter. 

7th  month  

Inches.      Lines. 
2            9 

Inches.           Lines. 
3                8 

Inches.                  Lines. 
2                     10 

7£        "       

3 

3                9 

3 

gth       "       » 

3            1 

3              10 

3                       1 

8}        " 

3            2 

4 

3                       2 

9th       "       

3            4 

4 

3                       4 

(See  Diameter  of  Fetal  Head,  page  57.) 

Bitgen  has  given  a  table  of  some  practical  value,  relative  to  the 
time  at  which  premature  delivery  may  be  effected ;  thus  it  may  be 
induced  at  the 


Inches. 

Lines. 

29th  week  when  the  antero-posterior  diameter  of  the  pelvis  is... 

...  2 

7 

30th     ' 

"                '• 

"                      "        ... 

...  2    , 

8 

31st      ' 

"                « 

"                      " 

...  2 

'     9 

35th      ' 

M                            (( 

It                     <l 

...  2 

10 

36th     ' 

«                            « 

««                      M 

...  2 

11 

37th      •                 "                «                       "            "            "     ... 

...  3 

0 

M.  Stoltz  has  given  the  bi-parietal  diameters  of  the  fetal  head  to  be 
from  the 

32d  to  the  33d  week  of  pregnancy 2|  inches. 

34th    "      35th        "  "        3£      " 

36th    "      37th        "  "        3        " 


INDUCTION    OF    PIIEMATURE    LABOR.  643 

The  rule  given  by  some  authors  is,  when  the  antero-posterior  diameter 
of  the  superior  strait  measures  three  inches,  to  delay  the  operation 
until  the  thirty-eighth  week,  or  eighth  month  ;  when  it  measures  but 
two  and  three-quarter  inches,  operate  at  seven  and  a  half  months;  and 
when  only  two  and  a  half  inches,  operate  at  the  seventh  month.  If 
the  diameter  is  less  than  two  inches,  an  attempt  must  be  made  to  save 
the  mother's  life  either  by  abortion  or  the  Cesarean  operation ;  and  I 
should  not  hesitate  a  moment  in  resorting  to  the  former  method,  which 
every  accoucheur  must  acknowledge  as  being  less  hazardous  in  its 
results  than  the  latter. 

In  cases  where  the  antero-posterior  diameter  of  the  superior  strait 
is  ascertained  to  be  three  and  a  quarter  inches,  and  where  in  previous 
pregnancy  the  fetus  could  be  delivered  only  by  a  resort  to  embryotomy, 
the  practitioner  is  justified  in  effecting  premature  labor;  but  not  in 
primiparaB,  with  whom  delivery  is  usually  possible,  even  under  such 
circumstances,  and  with  whom  it  is  not  advisable  to  operate  when  the 
diameter  measures  beyond  three  inches.  And  in  all  instances  the 
practitioner  should  be  well  assured  of  the  life  of  the  fetus  before 
attempting  the  operation,  bearing  in  mind  that  the  longer  the  child  is 
allowed  to  remain  within  the  uterus,  compatible  with  its  safe  delivery, 
the  greater  will  be  the  chances  in  favor  of  its  living  subsequently.  If 
the  existence  of  a  twin  pregnancy  be  satisfactorily  ascertained,  the 
operation  may  be  dispensed  with,  because  the  development,  as  well  as 
organization  of  twins,  is  usually  less  perfect  than  in  single  pregnan- 
cies; but  from  the  difficulty  in  determining  twin  pregnancies,  this  rule 

will  seldom  prove  of  any  practical  importance. 

<* 

There  are  other  conditions  beside  that  of  pelvic  contraction,  in 
which  the  induction  of  premature  labor  may  be  justifiable;  as  for 
instance,  in  cases  of  excessive  vomiting,  where  no  food  can  be  re- 
tained upon  the  stomach,  notwithstanding  various  remedial  agents 
have  been  administered,  and  where  consequently  the  life  of  the  mother 
is  threatened  by  starvation.  It  is  likewise  proper  in  all  cases  where 
the  continuance  of  pregnancy  adds  to  the  dangers  which  threaten  the 
life  of  the  female,  as  in  aggravated  diseases  of  the  heart;  in  aneurism, 
where,  from  the  obstruction  to  the  general  circulation  occasioned  by 
the  enlarged  uterus,  a  rupture  of  the  aneurismal  tumor  is  feared ;  in 
strangulated  hernia;  in  excessive  serous  effusions;  in  convulsions, 
especially  where  they  resist  the  remedial  means  pursued  and  recur 


G44  KING'S  ECLECTIC  OBSTETRICS. 

frequently,  becoming  at  the  same  time  more  and  more  severe ;  in 
uterine  hemorrhage,  more  particularly  when  owing  to  the  attachment 
of  the  placenta  over  the  inner  os  uteri  (placenta  prsevia);  in  diminu- 
tion of  the  bis-ischiatic  diameter;  in  abdominal  or  uterine  tumors, 
which  interfere  with  the  development  of  the  uterus  or  the  delivery  of 
the  fetus  at  full  term ;  in  case  there  has  been  a  rupture  of  the  uterus 
in  a  previous  labor;  and,  indeed,  in  all  cases  where  the  life  of  the 
mother  is  at  stake,  and  can  not  be  saved  by  any  other  means.  A  dead 
fetus  is  not  of  itself  a  cause  for  the  operation,  unless  there  be  other 
circumstances  of  a  hazardous  character  attending  it.  But  whatever 
may  be  the  nature  of  the  case,  it  must  not  be  forgotten  that  the  prac- 
titioner who  attempts  this  operation  assumes  a  very  heavy  responsi- 
bility, one  in  which  a  failure,  or  a  fatal  result  to  the  mother,  may 
seriously  involve  his  reputation  for  a  life-time ;  consequently,  as  a 
general  rule,  and  more  particularly  among  young  practitioners,  no 
operation  of  the  kind  should  be  undertaken  without  a  consultation  in 
the  matter,  and  the  sanction  of  the  consulting  physicians. 

Denmansays:  "There  is  another  situation  in  which  I  have  pro- 
posed and  tried  with  success  the  method  of  bringing  on  premature 
labor.  Some  women  who  readily  conceive,  proceed  regularly  in  their 
pregnancy  until  they  approach  their  full  period,  when,  without  any 
apparently  adequate  cause,  they  have  been  repeatedly  ^seized  with 
rigor,  and  the  child  has  instantly  died,  though  it  may  not  have  been 
expelled  for  some  weeks  after.  In  two  cases  of  this  kind  I  have  pro- 
posed to  bring  on  premature  labor  when  I  was  certain  the  child  was 
living,  and  have  succeeded  in  preserving  the  life  of  the  children 
without  hazard  to  the  mother.  There  is  always  something  of  doubt 
in  these  cases,  whether  the  child  might  not  have  been  preserved  with- 
out the  operation ;  but  as  such  cases  often  come  under  consideration, 
and  as  I  am  disclosing  all  that  my  experience  has  taught  me,  it  seemed 
necessary  to  mention  this  circumstance."  I  would  remark  here  that 
I  have  seen  similar  cases,  occurring  especially  after  a  bleeding  for 
fullness  of  the  head  or  other  unpleasant  symptom;  but  whether  they 
were  occasioned  by  the  bleeding  I  am  not  prepared  to  say,  but  make 
the  suggestion  for  future  investigation :  again,  I  have  witnessed  a  few 
instances  where  no  bleeding  has  been  performed. 

Females  sometimes,  in  a  succession  of  labors,  give  birth  to  still-born 
children,  and  which  is  owing,  not  to  pelvic  malformity,  but  to  a  pre- 
ternatural energy  of  the  contractions  of  the  uterus,  very  similar  to 
those  induced  by  Ergot,  being  permanent,  and  by  constant  compression 
.    of  the  cord  causing  a  suspension  of  the  fetal  circulation.     Premature 


INDUCTION   OF   PREMATURE   LABOR.  645 

delivery  has  been  recommended  in  such  cases,  with  an  intention  of 
lessening  the  energy  of  the  uterine  action,  or  a  hope  of  finding  it  less 
powerful  at  the  seventh  or  eighth  month,  in  consequence  of  which  the 
child  may  probably  be  saved.  But  the  operation  is  not  justifiable. 
The  disposition  to  excessive  uterine  contraction  may  be  overcome  by 
the  employment  of  uterine  tonics  and  antispasmodies  during  preg- 
nancy ;  and  anodynes  during  parturition,  with  rectal  injections  of  the 
officinal  compound  tincture  of  Lobelia  and  Capsicum,  slightly  diluted 
with  warm  water,  and  in  very  severe  and  obstinate  cases,  a  portion  of 
this  tincture  may  also  be  administered  internally,  or  the  Sp.  Tr.  of 
Gelsemium. 

It  can  not  be  denied  that  there  are  several  difficulties  which  inter- 
fere in  a  greater  or  less  degree,  with  the  success  of  the  operation; 
thus,  the  size  of  the  pelvis  may  be  inaccurately  estimated,  and  the 
operation  be  performed  at  too  late  a  period,  or  too  early,  to  insure  the 
subsequent  existence  of  the  child.  Frequently  it  is  almost  if  not 
quite  impossible  to  precisely  determine  the  age  of  the  pregnancy,  as 
women  are  very  apt  to  be  mistaken  in  their  calculations,  and  the 
results  may  be  similar  to  those  just  mentioned  above ;  but  notwith- 
standing these  difficulties,  they  are  by  no  means  of  such  a  nature  as 
to  lead  us  to  reject  the  operation,  the  results  of  statistics  being  greatly 
in  its  favoj.  Again,  abnormal  presentations,  as  of  the  shoulder, 
breech,  etc.,  are  more  frequent  in  premature  labors,  for  wThich  no  sat- 
isfactory reason  has  been  given,  and  which  generally  prove  fatal  to 
the  child,  owing  to  the  constant  pressure  on  the  umbilical  cord  during 
the  passage  of  the  fetal  head  through  the  brim ;  or,  where  the  presen- 
tation is  natural,  the  fetus  may  be  destroyed  by  a  long-continued 
compression  of  the  uterus  upon  it,  owing  to  the  escape  of  the  water 
and  the  delay  in  dilatation  of  the  os  uteri.  But  none  of  these 
obstacles  are  of  so  grave  a  nature  as  to  prohibit  the  operation, -because 
the  life  of  the  mother  is  to  be  considered  as  of  the  first  importance, 
and  that  of  the  child  as  secondary — to  be  saved,  if  possible,  but 
always  without  endangering  the  mother. 

I  would  refer  here  to  an  ancient  prejudice  which  is  still  very  popular, 
and  is  even  supposed  to  be  true  by  many  physicians ;  it  is,  that  a  child 
born  at  the  seventh  month  is  more  apt  to  live,  than  one  born  at  the 
eighth  month  of  pregnancy.  This,  however,  is  very  absurd  and 
incorrect ;  for  we  would  suppose  that  the  longer  the  intra-uterine  life 
is  extended,  the  greater  would  be  the  chances  for  a  perfect  develop- 
ment of  organization,  and  consequently  o*f  a  subsequent  independent 


646  KING'S  ECLECTIC  OBSTETRICS. 

existence,  and  such  is  actually  found  to  be  the  case  in  practice.  I  am 
aware  that  "  eighth  month  children,"  as  they  are  called,  frequently 
die  at  a  very  early  age,  and  I  am  likewise  aware  that  "seventh  month  " 
and  "ninth  month  children"  frequently  meet  with  a  similar  early 
death;  but  I  have  found  no  peculiar  tendency  of  this  kind  among 
those  born  at  the  eighth  month. 

Various  methods  have  been  devised  and  recommended  for  the  pre- 
mature expulsion  of  the  fetus,  some  of  which  may  prove  safe,  as  far 
as  the  mother  is  concerned,  but  are  necessarily  fatal  to  the  child  ; 
while  others  have  in  view  the  safety  of  both  mother  and  child.  The 
former  are  seldom  employed  unless  the  intention  is  to  produce  abor- 
tion, previous  to  the  seventh  month  or  viable  condition  of  the  child  ; 
and  it  should  never  be  attempted  unless  the  antero-posterior  diameter 
of  the  superior  strait  is  less  than  two  and  a  half  inches.  In  these 
cases  the  question  is  between  abortion  and  the  Cesarean  section  ;  by 
the  former  the  child  is  delivered  dead,  while  the  hazard  to  the  mother 
is  comparatively  small;  by  the  latter,  the  child  has  one  chance  in  three 
of  living,  while  the  mother  has  but  one  in  two  and  a  quarter  chances 
of  recovering  from  the  operation.  Shall  we  then  sacrifice  the  child 
to  save  the  mother,  or  the  mother  to  save,  probably,  neither  ?  My 
own  view  of  the  matter  corresponds  with  that  of  Velpeau,  who  says : 
"  As  regards  myself,  I  avow  I  can  not  put  in  comparison  Hie  precious 
life  of  a  fetus  of  three,  four,  five,  or  six  months,  a  being  scarcely 
differing  from  a  plant,  one  that  is  bound  by  no  ties  to  the  external 
world,  with  that  of  an  adult  woman,  whom  a  thousand  social  relations 
interest  us  to  save  :  therefore,  in  a  case  of  extreme  narrowness  of  the 
pelvis,  and  where  it  was  mathematically  demonstrated  that  delivery  at 
the  full  period  was  impossible,  I  would  not  hesitate  to  recommend 
producing  abortion  in  the  first  months  of  gestation." 

Abortion  may  in  some  cases  be  effected  by  warm  pediluvia,  copious 
sweating,  and  drastic  purgation,  while  in  others  these  will  produce  no 
influence  at  all ;  indeed,  many  unchaste  females  are  in  the  habit  of 
producing  abortion  in  the  early  months  of  pregnancy  whenever  this 
takes  place,  by  such  means  as  named  above,  yet  it  is  generally  accom- 
plished at  a  great  sacrifice  to  both  health  and  long  life.  The  oil  of 
Savin  given  in  doses  of  ten  drops  on  sugar,  and  repeated  three  times 
daily  for  a  week  or  two,  will  cause  abortion,  especially  in  the  early 
months  of  gestation,  in  consequence  of  its  destructive  influence  upon 
the  ovum,  yet  it  frequently  .fails,  and  if  given  in  larger  quantities  is 
very  apt 'to  produce  serious  inflammation;  its  action  appears  to  be 


INDUCTION    OF    rilEMATUKK    LAUOli.  647 

more  positive  in  females  of  a  strumous  diathesis.  Borax  and  Cinna- 
mon in  doses  of  five  grains  each,  or  a  mixture  of  Borax  and  Ergot, 
each,  in  powder,  ten  grains,  powdered  Cinnamon  one  scruple,  admin- 
istered three  times  a  day,  will  likewise  often  occasion  abortion,  l>v 
their  influence  upon  the  contractile  tissue  or  action  of  the  uterus,  yet 
these  compounds  sometimes  produce  irremediable  and  distressing 
symptoms.  Many  other  agents  have  produced  abortion  as  various 
essential  oils,  or  infusions  of  emmenagogue  herbs,  with  or  without  the 
addition  of  Yeast,  etc.,  but  none  of  these  can  be  recommended  as 
invariably  certain  in  their  results,  beside  which,  they  often  produce 
disastrous  consequences. 

A  solution  of  half  a  grain,  or  a  grain  of  Sulphate  of  Iron  in  two 
fluidrachms  of  water,  carefully  injected  into  the  pregnant  uterus,  is 
much  employed  among  abortionists  to  effect  their  object.  Another 
plan,  which  is  considerably  used,  is  to  pass  up  a  Simpson's  sound  into 
the  uterus,  feel  around  with  it  for  the  placenta  and  detach  a  small 
portion  of  its  periphery,  enough  to  cause  a  little  blood  to  flow;  in 
twelve  or  twenty-four  hours,  the  uterus  contracts  and  sooner  or  later 
expels  its  contents.  It  is  Hardly  worth  while  to  state  to  the  medical 
student,  the  dangers  that  are  apt  to  follow  abortions  thus  effected, 
nor  the  slavery  and  the  legal  liabilities  to  which  the  operators  are 
subject. 

Probably  the  safest  as  well  as  the  most  certain  method  is  the  one 
pursued  by  Macauley  in  1756 — perforation  of  the  membranes  by  the 
introduction  of  a  catheter  or  a  canula  armed  with  a  trocar;  the  in- 
strument is  introduced  into  the  os  uteri,  and  the  membranes  pierced 
by  it,  care  being  taken  not  to  injure  the  parts  of  the  mother.  This 
method  is  neither  painful  nor  injurious  to  the  mother;  by  it,  the 
amniotic  liquid  escapes,  the  uterine  walls  retract,  dilatation  of  the  os 
uteri  more  or  less  slowly  ensues,  requiring  from  twenty  to  forty  hours, 
and  in  some  instances  even  sixty ;  the  uterus,  irritated  by  the  constant 
proximity  of  the  fetus,  contracts,  but  is  unable  to  expel  its  contents 
until  the  os  uteri  has  become  sufficiently  dilated,  hence  there  is  fre- 
quently excessive  hemorrhage  from  an  early  detachment  of  the  pla- 
centa. This  method  has  been  also  advised  to  induce  premature 
delivery,  but  it  should  never  be  adopted  after  the  seventh  month,  :is 
from  the  early  discharge  of  the  waters  and  consequent  prolonged 
pressure  of  the  uterus  upon  the  fetus,  its  life  is  greatly  endangered. 

The  above  methods  are  among  those  which  have  been  used  at 
various  times  for  the  purpose  of  producing  abortion,  but  in  instances 
where  it  is  required  to  save  the  life  of  the  child,  if  possible,  that  is, 


648  KING'S  ECLECTIC  OBSTETRICS. 

after  the  seventh  month,  other  measures  have  been   recommended, 
among  which  may  be  mentioned  the  following: 

1.  Frictions  over  the  fundus  uteri  to  induce  contractions,  at  the 
same  time  titillating  or  irritating  the  os  uteri  by  one  or  more  lingers 
introduced  into  the  vagina,  has  been   proposed  by  D'Outrepont  and 
Ritgen;  this  plan,  however,  is  rarely  employed,  because  it  seldom 
effects  any  uterine  contractions,  and  when  these  do  occur,  they  are  too 
feeble  and  evanescent  to  produce  an  expulsion  of  the  fetus. 

2.  It  has  been  suggested  by  Dr.  Hamilton,  to  introduce  a  finger  or 
gum-elastic  catheter  beyond  the  inner  os  uteri,  and  separate  the  mem- 
branes from  the  internal  uterine  surface  for  some  two  or  three  inches 
around,  and  where  labor  can  be  brought  on  by  this  mode,  it  is  safe  to 
both  mother  and  child.     But  it  can  not  be  relied  upon  as  an  efficient 
measure,  and  in  cases  where  it  has  succeeded,  the  result  was  probably 
brought  about  by  the  irritation  produced  at  the  cervix.     What  has 
been  termed  catheterization  of  the  uterus  has  usually  been  regarded 
as  quite  certain  in  its  action.     It  consists  in  introducing  an  ejastic 
catheter  or  bougie  between  the  membranes  and  the  walls  of  the  uterus, 
allowing  it  to  remai.n  in  situ  until  contractions  follow.      This  method 
has  been  improved  upon  by  Professor  Lazarewitch,  who  passes  an 
elastic  tube  between  the  uterus  and  its  membranes,  from  the  cervix  to 
the  fundus,  or  as  nearly  so  as  possible,  and  then  injects  through  this 
tube  from  eight  to  ten  ounces  of  warm  water ;  in  twelve  cases,  uterine 
contraction  came  on  at  once,  nine  of  the  children  were  born  alive,  and 
none  of  the  mothers  died.     Two  of  the  cases  required  a  second  in- 
jection to  urge  the  uterus  to  greater   action.     The  labors   by  this 
method  usually  come  on  in  from  ten  to  twenty-four  hours,  and  ter- 
minate in  from  sixteen  to  twenty-four  hours.     This  is  not  a  painful 
mode,  and  is  supposed  by  its  originator  to  produce  an  effect  somewhat 
similar  to  the  natural  process,  in  which  he  claims,  that  the  initiative 
step  in  labor  is  detachment  of  the  membranes  from  the  uterine  wall — 
that  this  detachment,  as  well  as  uterine  contraction,  commences  at  the 
fundus — and  that  the  contractions  are  not  manifested  until  the  detach- 
ment has  occurred.     Although  this  method  has  proved  successful  in 
many  cases,  yet  it  has  in  other  cases  occasioned  alarming  symptoms, 
and  even  death,  which  should  lead  to  some  hesitation  in  resorting 
to  it. 

3.  M.  Meissner,  of  Leipsic,  has  given  a  plan  by  which  he  assures 
us  that,  in  fourteen  cases  upon  whom  it  was  tried,  both  mother  and 
child  were  saved  in  every  instance ;  it  is  an  improvement  upon  the 
method  of  Macaulay,  and  has  for  its  object  the  gradual  discharge  of 


INDUCTION    OF    PREMATURE    LABOR.  649 

the  amniotic  liquid,  thereby  avoiding  long-continued  pressure  upon 
the  fetus.  The  plan  is  to  puncture  the  membranes,  not  at  their 
lowest  part,  but  high  up,  as  near  the  fundus  uteri  as  possible ;  and 
the  instrument  he  employs  is  a  canula  about  thirteen  inches  in  length, 
and  two  lines  in  diameter,  and  having  a  curve  corresponding  with  the 
segment  of  a  circle  whose  radius  is  eight  inches.  Attached  to  this 
canula  are  two  stilets,  one  bearing  at  its  extremity  an  olive-shaped 
button,  the  other  a  trocar;  a  ring  is  also  placed  upon  the  lower 
extremity  of  the  convex  side  of  the  canula,  which  enables  the  operator 
to  determine  the  direction  of  the  curvature  when  the  instrument  is 
within  the  uterus.  The  female  being  placed  in  an  erect  position,  the 
operator,  stooping  down  on  one  knee,  proceeds  carefully  to  introduce 
the  canula  armed  with  the  olive-shaped  button  through  the  os  uteri, 
and  as  far  up  between  the  membranes  and  uterine  walls  as  possible, 
say  six,  eight,  or  ten  inches  above  the  os  uteri.  This  having  been 
accomplished,  and  also  having  ascertained  that  the  point  of  the  canula 
is  not  in  contact  with  any  part  of  the  fetus,  the  button  stilet  is  with- 
drawn, and  that  'with  the  trocar  introduced  and  the  membranes 
punctured.  Sometimes,  when  the  cervix  is  high  up,  and  looking  so 
far  backward  as  to  be  reached  with  difficulty,  the  female  will  have  to 
sit  on  the  edge  of  a  chair,  or  assume  the  recumbent  position,  in  order 
to  enable  the  practitioner  to  introduce  the  canula.  After  the  perfora- 
tion of  the  membranes,  the  trocar-stilet  is  removed,  a  small  portion 
of  fluid  is  permitted  to  pass  through  the  canula,  and  then  this  is  also 
withdrawn.  The  waters  by  this  mode  escape  gradually,  pains  usually 
come  on  in  twenty-four  or  forty-eight  hours,  and  labor  is  finished  in 
from  thirty-six  to  sixty  hours.  This  operation  has  not  been  very 
extensively  employed,  but  is  preferable  to  any  of  the  plans  heretofore 
named,  although  rather  difficult  to  satisfactorily  accomplish. 

4.  Kluge  has  proposed  a  mode  of  inducing  uterine  contractions 
without  puncturing  the  membranes,  by  the  introduction  of  a  sponge- 
tent  within  the  os  uteri.  The  sponge  must  be  soft  and  fine,  of  a 
conical-  shape,  about  two  inches  long,  and  half  an  inch  in  diameter  at 
its  base,  and  a  piece  of  tape  must  be  attached  to  its  base,  by  means  of 
which  it  may  be  removed  when  required.  It  may  be  prepared  by 
soaking  a  piece  of  fine  sponge  in  a  solution  of  Gum  Arabic,  wrapping 
it  round  an  awl,  and  tightly  binding  it  on  by  a  string ;  when  dry,  it 
can  be  cut  into  any  required  shape.  The  female,  for  a  few  day.- 
previous  to  the  operation,  is  directed  to  use  the  warm-bath,  and  warm 
•emollient  and  narcotic  vaginal  injections ;  and  before  introducing  the 
.sponge,  both  the  rectum  and  bladder  are  to  be  emptied.  She  is  then 


650  KING  8    ECLECTIC    OBSTETRICS. 

to  be  placed  in  a  position  somewhat  similar  to  that  required  for  the 
application  of  the  forceps,  and  the  finger  of  the  operator  is  introduced 
into  the  vagina  as  far  as  the  os  uteri  to  serve  as  a  conductor;  with  the 
other  hand,  a  long  pair  of  forceps,  holding  the  piece  of  sponge,  is  to- 
be  passed  along  the  conducting  finger  and  gradually  entered  within  the 
canal  of  the  cervix.  After  holding  it  there  for  a  few  minutes  the 
forceps  are  to  be  withdrawn,  and  the  sponge  kept  in  its  place  by  filling 
the  vagina  with  a  large  sponge,  or  pieces  of  linen,  and  the  whole 
retained  by  a  proper  bandage;  the  patient  is  then  directed  to  remain 
in  bed.  The  fluids  of  the  parts  saturate  the  sponge,  which  swells  up, 
and  consequently  dilates  the  os  uteri,  and  irritates  its  fibers,  which, 
reacting  upon  those  of  the  corpus  uteri,  effects  contractions,  which 
usually  occur  in  five  or  six  hours.  If,  in  the  course  of  twenty-four 
hours,  active  contractions  of  the  uterus  are  not  excited,  the  sponge 
must  be  removed  by  means  of  the  tape,  and  a  new  and  larger  piece 
inserted  in  its  place ;  this  second  application  is  most  generally 
successful.  If  required,  the  labor-pains  may  be  increased  by 
titillating  the  cervix,  frictions  over  the  abdomen,  and  the  use  of 
Macrotys  or  Ergot  This  plan  is  a  good  one,  and  certainly  preferable 
to  that  of  puncturing  the  membranes,  yet,  it  is  stated  to  fail  occasion- 
ally. Sea  tangle-tents  have  likewise  been  used  for  the  same  purpose, 
and  are  said  to  act  better  than  the  sponge,  as  they  give  rise  to  less 
irritation,  dilate  the-os  more  gradually,  and,  when  hollow,  permit  the 
escape  of  the  discharges. 

5.  Professor  Kiwisch,  of  Wurzburg,  recommends  the  direction  of  a 
stream  of  warm  water  from  a  height,  by  means  of  a  syphon,  continu- 
ously upon  the  os  uteri;  Dr.  Smith  proposes  to  improve  upon  this 
method, by  alternating  the  temperature  of  the  douche  from  hot  to 
cold.  A  vessel  capable  of  holding  two  gallons  of  water  is  placed  at 
an  elevation  of  four  or  five  feet  above  the  patient,  to  which  is  affixed  a 
flexible  tube,  about  eleven  feet  in  length  and  half  an  inch  in  diameter, 
the  uterine  extremity  of  "which  terminates  in  an  ivory  or  bone  nozzle 
five  or  six  inches  in  length,  or  is  connected  with  the  straight  tube  of 
an  injecting  apparatus,  and  near  the  upper  end  of  which  a  stop-cock 
is  attached.  In  employing  this,  two  gallons  of  warm  water,  about 
110°  F.,  are  to  be  placed  into  the  vessel.  The  uterine  extremity  of 
the  tube  is  then  passed  into  the  vagina  and  directed  toward  the  os 
uteri,  the  female  being  in  bed,  or  in  an  empty  hip-bath;  holding  the 
tube  steadily,  the  stop-cock  is  turned,  and  the  stream  immediately 
commences  flowing  with  considerable  force  against  the  os  uteri,  and 
which  is  to  be  continued  until  the  whole  two  gallons  have  been  dis- 


INDUCTION    OF    PREMATURE    LABOR.  651 

charged.  If  this  is  to  be  followed  by  a  cold  douche,  the  same  quantity 
of  cold  water  is  to  be  poured  into  the  vessel  as  soon  as  it  is  emptied, 
and  allowed  to  flow  in  the  same  manner.  The  time  occupied  in  the 
operation  is  from  twenty  to  thirty  minutes,  and  the  only  disagreeable 
sensations  experienced  are  when  the  warm  and  cold  currents  first  begin 
to  run.  This  operation  may  be  repeated  two  or  three  times  daily, 
requiring  its  application  from  two,  to  four,  eight,  or  twelve  times.  It 
is  to  be  preferred  to  all  others  yet  named,  as  its'  application  is  simple, 
and  no  possible  injury  can  be  done  to  either  the  mother  or  child. 
However,  it  is  not  only  a  troublesome,  unpleasant  method,  but  gen- 
erally quite  a  tedious  one.  If  expedient,  it  should  be  performed  at 
the  period  in  which  the  catamenia  would  have  appeared  in  the  non- 
pregnant  condition.  A  syringe  capable  of  maintaining  a  continuous 
stream  may  be  substituted  for  the  vessel  and  tube. 

6.  The  employment  of  galvanism  or  electro-magnetism,  as  suggested 
by  Herder  in  1803,  has  been  found  efficacious  in  bringing  on  uterine 
contractions,  even  after  other  means  had  failed.  This  is  accomplished 
by  placing  one  pole  of  the  battery  on  either  side  of  the  uterus,  con- 
tinuing the  application  of  the  current  for  half  an  hour  or  an  hour 
each  time,  and  renewing  it  once  or  twice  daily;  the  ordinary  electro- 
magnetic apparatus  in  use  is  the  best  form,  as  repeated  shocks  prove 
more  effectual  and  certain  in  stimulating  the  uterus  to  contractions 
than  a  continued  current.  In  applying  the  poles'  it  will  be  proper  to 
attach  to  the  discs  a  sponge  moistened  with  water,  or  salt  and  water; 
or  pieces  of  thin  flannel  likewise  moistened  may  be  placed  between 
the  discs  and  the  abdomen.  Some  apply  one  pole  to  the  neck  of  the 
uterus,  and  the  other  to  the  spine  or  abdomen,  immediately  above  the 
fundus;  but  this  is  unnecessary.  Dr.  Radford  states,  "  that  galvanism 
not  only  originates  the  temporary  contractions  of  the  uterus,  but  also 
produces  such  a  lasting  impression  on  the  organ  that  pains  continue 
to  occur  until  the  labor  is  terminated.  It  produces  severe  pains  in 
the  loins,  and  great  bearing  down,  followed  by  dilatation  of  the  os,. 
and  expulsive  pains."  I  have  employed  this  agent  in  a  few  cases,  and 
with  invariable  success,  though  the  number  and  intensity  of  the  appli- 
cations had  necessarily  to  be  varied  in  each.  In  relation  to  its  influ- 
ence on  the  fetus,  Dr.  Radford,  who  has  made  extensive  employment 
of  it  in  midwifery,  states  that  he  has  never  observed  that  the  child  in 
utero  has  been  injured  by  its  use,  which  gives  it  a  great  advantage 
over  the  administration  of  secale  cornutum,  which,  in  many  cases,  is 
destructive  of  it;  he  also  remarks,  "Galvanism  is  especially  advanta- 
geous as  a  general  stimulant  in  all  those  cases  in  which  the  vital 


KINGS  ECLECTIC  OBSTETRICS. 

powers  are  extremely  depressed  from  loss  of  blood.  Its  beneficial 
effects  are  to  be  observed  in  the  change  of  countenance,  restoring  an 
animated  expression;  in  its  influence  on  the  heart  and  arteries;  in 
changing  the  character  of  respiration;  and  its  warming  influence  on 
the  general  surface.  I  have  several  times  observed,  in  cases  in  which 

O  * 

other  powerful  stimulants  have  failed  to  produce  any  beneficial  results, 
the  most  decided  advantages  accrue  after  its  application."  It  may 
likewise  be  employed  to  effect  abortion,  when  the  indications  show  the 
necessity  for,  or  justify,  the  expulsion  of  the  ovum.  This  method  is 
also  somewhat  tedious. 

7.  The  fresh  Inner  Bark  of  the  Root  of  the  Cotton  plant  is  stated 
by  Dr.  Bouchelle  to  have  a  particular  affinity  for  the  sexual  organs, 
modifying  their  functions  in  a  remarkable  manner;  that  it  not  only 
possesses  oxytocic  properties,  invigorating  feeble  contractions  of  the 
uterine   fibers,  but   that   it  originates   expulsive   contraction    at  any 
period  of  gestation,  and  will  induce  immediate  abortion  when  taken  in 
the  proper  quantity,  and  without  any  detriment  to  the  health  of  the 
female.     He  states,  also,  that  it  was  habitually  resorted  to  by  slaves 
in  the  South  as  an  ecbolic  for  the  criminal  purpose  of  inducing  abor- 
tion, a  fact  which  I  have  in  past  years  had  named  to  me  a  number  of 
times  by  Southern  practitioners.     Dr.  B.  infers,  from  its  influence  on 
females,  that  the  use  of  it  destroys  the  generative  capacity,  rendering 
the  person  sterile,  without  impairing  the  health  ;  should  this  eventually 
prove  to  be  the  case,  the  bark  of  cotton  root  will  become  a  most 
important  article  of  our  materia  medica,  a  boon  to  physicians,  and 
likewise  to  females  with  deformed  pelves;  and  it  is  to  be  desired  that 
its  value  in  this  matter  will 'be  thoroughly  investigated.     It  is  used  in 
strong  decoction  as  an  ecbolic  or  oxytocic,  of  which  four  fluidounces 
may  be  taken  every  twenty  or  thirty  minutes  until  the  desired  result 
is  obtained.     It  is  quite  difficult  to  obtain  the  recent  root  to  use  in 
decoction;  owing  to  this  fact,  the  specific  tincture  will  probably  be 
found  the  most  reliable  preparation  on  the  market.     It  may  be  used 
in  from  five  to  ten  drop  doses  every  two  or  three  hours  until  the 
effect  is  perceptible. 

8.  Professor  Giordano,  of  Turin,  advises  the  application  of  solid 
nitrate  of  silver  to  the  cervix,  as  being  of  easy  execution,  prompt  and 
complete  in  its  results,  and  followed  by  no  ill  consequences.     Having 
introduced  the  caustic  within  the  cervix,  he  imparts  to  it  repeated,  but 
slight,  rotatory  movements,  so  that  most  of  the  surface  may  undergo 
the  process  of  cauterization.     This,  however,  I  do  not  consider  a  safe 
method,  and  it  is  certainly  one  for  which  there  is  no  necessity. 


INDUCTION    OF    PREMATURE    LABOR. 


653 


9.  Probably  the  best  and  most  ready  method  at  present  known  to 
the  profession  is  the  use  of  India-rubber  bags,  which  act  somewhat 
similarly  to  the  natural  bag  of  waters,  and  effect  safe  delivery  in  from 
one  to  six  hours,  without  any  danger  of  injury  to  the  mother  or  child. 
These  bags  are  of  several  sizes,  and  have,  at  one  extremity,  a  long 
elastic  tube  with  stop-cock  attached.  Commencing  with  the  smallest, 
this  is  well  oiled,  then  introduced  into  the  cervix  uteri  and  a  little 
beyond  the  inner  os,  and  air  or  warm  water  is  injected  into  it  through 
the  tube.  If  required,  the  next  size  is  then  employed  in  the  same 
manner,  and  so  on.  Dr.  W.  Molesworth,  of  New  York  city,  has 
made  a  decided  improvement  upon  these  elastic  bags  in  what  he  terms 
his  "climax  dilator,"  which  is  more  convenient;  can  be  employed 
with  greater  facility;  does  not  increase  in  length,  but  dilates  uniformly 
from  side  to  side;  can  be  used  with  either  air  or  warm  water,  the  latter 
being  preferable;  and  the  degree  of  dilatation  of  which  can  at  all 
times  be  determined  by  the  amount  of  water  employed.  It  is  also 
exceedingly  useful  in  placenta  prsevia  and  other  conditions,  in 
which  it  becomes  necessary  to  promptly  effect  dilatation  of  the  os 
uteri,  as,  in  operations  for  uterine  polypus,  fibroid  tumor,  etc.*  (See- 
Fig.  94). 

FIG.  94. 


MOLESWORTH'S  CLIMAX  DILATOR. 

After  uterine  contractions  have  been  fully  established  by  the 
adoption  of  either  of  the  above  measures,  to  induce  premature  de- 
livery, the  labor  will  proceed  in  the  same  manner  as  at  full  term,  and 
its  management,  as  well  as  that  of  the  placenta,  will  also  be  the  same 
as  recommended  at  that  period..  As  a  prematurely  delivered  child  is 
more  feeble  than  one  fully  developed,  some  care  will  be  required  in 
its  management;  it  should  be  kept  warm,  allowing  it,  however,  a  free 
use  of  its  limbs,  and  a  wet  nurse  should  always  be  provided  for  it, 
who  should  be  directed  to  adopt  a  system  of  regularity  in  applying  it 
to  the  breast,  at  no  time  allowing  it  an  excess  of  aliment. 


654  KING'S  ECLECTIC  OBSTETRICS. 


CHAPTER    XLVIII. 

PUERPERAL     FEVER PERITONITIS PUERPERAL      SEPTICEMIA  - 

INFLAMMATION    OF    THE    UTERINE    APPENDAGES — METRITIS 

—UTERINE    PHLEBITIS INFLAMMATION    OF    THE 

UTERINE    ABSORBENTS — TREATMENT 
OF    PUERPERAL    FEVER. 

ONE  of  the  most  dangerous  forms  of  disease  to  which  the  puerperal 
woman  is  liable,  is  that  commonly  known  as  PUERPERAL  or 
CHILD-BED  FEVER — concerning  which  there  have  been,  from 
time  to  time,  various  and  discordant  opinions  expressed  by  medical 
writers,  as  well  as  sundry  modes  of  treatment  recommended,  each 
being  based  upon  the  particular  theory  supported  by  its  originator. 
This  clashing  of  views  has,  perhaps,  originated  from  the  fact,  that  the 
malady  termed  puerperal  fever,  has  included  several  phenomena  which 
have  not  been  uniform,  and  which  have  yielded  to  the  most  opposite 
plans  of  treatment — and,  each  writer  being  entirely  governed  in  his 
opinions  upon  the  subject,  by  the  particular  symptoms  and  circum- 
stances presented  to  his  individual  notice,  has,  probably,  been  induced 
to  infer  that,  while  others  have  mistaken  the  true  nature  of  the  disease, 
he  has  correctly  ascertained  it,  together  with  the  best  treatment  for  its 
cure.  At  the  present  day  it  is  generally  acknowledged  that  the  malady 
varies  in  its  pathological  characteristics.  It  has  been  variously  called 
puerperal  peritonitis,  puerperal  metrophlebitis,  puerperal  pyemia,  and 
puerperal  septicemia;  the  latter  being  probably  the  more  correct  term,  to 
apply  to  the  severe  and  rapidly  fatal  form  of  the  disease  which  occurs 
shortly  after  parturition.  Professor  J.  Matthews  Duncan,  M.  D.,  of 
Edinburgh,  Scotland,  in  an  address  to  the  British  Medical  Association 
at  Norwich,  August,  1874,  in  the  course  of  his  remarks,  observed :  "  Xo 
theory  of  this  subject  (child-bed  fever)  can  be  regarded  as  final  or  sure. 
But  the  time  has  come  when  obstetricians  should  try  to  leave  off  the 
use  of  the  convenient  term  puerperal  fever,  because  it  embodies  error. 
There  is  nothing  essentially  puerperal  known  in  it;  nor  is  there  any 
thing  of  the  nature  of  a  fever,  as  that  term  is  generally  understood. 
A  new  name,  already  widely  used,  is  to  be  found  in  the  already  com- 
paratively old  term  pyemia.  This  new  name  can  be  of  only  temporary 
utility,  but  that  utility  wilJ  be  very  great,  and  continue  till  advancing 
science  displaces  it  by  a  better,  as  it  should  now  displace  puerperal  or 


PUERPERAL    FEVER.  655 

child-bed  fever.  It  will  then  have  served  its  time  by  carrying  the 
ideas  of  generations  of  practitioners  away  from  the  old,  flimsy,  and 
extensively  erroneous  speculations  of  the  past  to  the  more  substantial 
of  this  day." 

Puerperal  fever  (pyemia)  has,  heretofore,  proved  very  fatal  in  its 
result,  destroying  a  large  majority  of  those  who  have  been  attacked 
by  it,  and  has  undoubtedly  occasioned  more  than  two-thirds  of  the 
deaths  which  have  occurred  among  females  at  the  puerperal  period. 
It  is  stated  to  be  more  malignant  in  hospital  than  in  private  practice, 
which  may  be  owing  to  the  congregation  of  too  many  patients  in  a 
ward,  as  well  as  to  a  neglect  of  proper  ventilation,  and  thorough  and 
constant  cleanliness  of  the  various  lying-in  apartments.  The  poorer 
classes  of  society,  from  their  indigent  mode  of  living,  and  the  illy- 
ventilated,  unclean,  and  damp  rooms,  which  their  circumstances  compel 
them  t&  occupy,  are  also  said  to  be  more  subject  to  the  disease  than 
those  who  can  obtain  the  proper  necessaries  and  conditions  for  health, 
and  it  also  proves  much  more  fatal  among  them. 

The  attack  commonly  occurs  within  two  or  three  days  after  delivery, 
but  it  has  been  met  with  previous  to  labor,  and  also  at  the  third  or 
fourth  week  succeeding  it,  depending  upon  the  peculiar  form  or  variety 
of  the  disease,  its  cause,  etc.;  and  when  it  does  occur,  it  usually  runs 
its  course  speedily. 

CAUSES. — Puerperal  fever  most  generally  prevails  as  an  endemic, 
and  it  is  not  uncommon,  at  endemical  seasons,  to  observe  that  nearly 
every  puerperal  woman  within  the  abnormal  district  suifers  from  an 
attack.  This  may  be  owing  to  the  great  susceptibility  which  the  parts 
must  have  to  diseased  action,  arising  from  the  nervous  shock,  the 
sudden  evacuation  of  the  abdominal  cavity,  the  powerful  contractions 
of  the  uterus  and  abdominal  muscles,  and  other  circumstances  con- 
nected with  labor,  and  more  especially  to  the  wound*  in  the  uterus, 

*  "But  it  is  not  *  *  *  to  be  supposed  that  practitioners  are  not  bound  by  the 
most  solemn  considerations  to  take  most  scrupulous  care  against  being  disseminators 
of  disease ;  and  there  is  no  disease  with  which  they  deal,  where  such  care  is  more 
imperative  in  them  than  puerperal  pyemia.  The  puerperal  woman  presents  in  her 
contused,  lacerated,  and  inevitably  wounded  passages  the  most  i'avorable  nidus  for  the 
reception  of  morbific  material;  and  the  woman  suffering  from  puerperal  pyemia  in  any 
of  its  forms,  and  the  patient  suffering  from  some  of  the  allied  diseases,  present  this 
morbific  material  in  its  subtlest  and  most  potent  essence.  A  well-demonstrated  com- 
municability  arises  from  this  source.  No  other  has  been  demonstrated,  but  it  is  possible 
that  in  an  ill-managed  hospital  there  may  be  some  other.  For  the  existence  of  another 
source,  several  of  the  best  recent  authors  offer  slight  evidence ;  but,  on  the  other  hand, 
its  existence  is  rendered  very  doubtful  by  the  alleged  absence  of  pyemia  in  those  sur- 
gical hospitals  or  parts  of  hospitals  where  the  antiseptic  treatment  of  Lister  is  properly 
•carried  out". — Prof.  J.  Matthews  Duncan. 


656  KING'S  ECLECTIC  OBSTETRICS. 

resulting  from  the  detachment  of  the  placenta,  to  contusion  of  the- 
lymphatics,  or  to  laceration  of  any  portion  of  the  genital  passage,  in 
association  with  putrefied  material  from  decomposed  particles  of 
placental  or  decidual  tissue,  or  of  the  lochial  discharge,  and  which  is 
undoubtedly  the  chief,  if  not  the  only,  cause  of  the  true  puerperal 
disease ;  indeed,  when  we  consider  all  the  phenomena  present  during 
the  birth  of  a  child,  and  more  especially  in  difficult,  and  instrumental 
labors,  it  is  rather  a  source  of  astonishment,  that  the  disease  is  not 
still  more  frequently  met  with.  When  occurring  as  an  endemic,  it  is 
more  malignant  and  fatal  in  its  character  than  when  it  exists  auto- 
genetically,  and  those  females  more  readily  fall  victims  to  it,  who  are 
exposed  to  any  of  the  causes  hereafter  assigned  for  its  spontaneous 
advent. 

Independently  of  an  endemic  origin,  puerperal  fever,  it  has  been 
stated,  may  be  produced  by  an  exposure  to  cold,  or  to  dampness;  by 
an  omission  of  the  bandage;  by  the  female  arising  from  her  bed  at  too 
early  a  period;  by  allowing  her  improper  food,  or  stimulants,- during 
the  first  puerperal  week ;  by  violent  emotions  of  the  mind,  whether 
of  a  depressing  or  exciting  character;  by  a  retention  of  portions  of 
the  placenta;  by  want  of  cleanliness  and  ventilation;  it  may  likewise 
follow  hemorrhage,  manual  or  instrumental  operations,  and,  not- 
withstanding that  venesection  is  frequently  recommended  as  a  means 
to  overcome  the  disease,  yet  we  find  that  it  frequently  follows  exces- 
sive floodings.  I  have  several  times'  noticed  a  disease  resembling  it 
(intestinal  irritation),  to  follow  a  constipated  condition  of  the  bowels, 
in  cases  where  the  attending  accoucheur  had  permitted  the  patient 
to  remain  without  any  alvine  evacuation  for  ten  or  twelve  days. 
Manual  and  instrumental  labors  frequently  render  the  puerperal 
female  especially  obnoxious  to  this  disease.  And  again,  it  is  often 
impossible  to  assign  any  satisfactory  cause  for  its  origin. 

It  has  also  been  supposed  to  have  been  produced  or  modified  in  its 
character  by  the  presence  of  scarlatina,  small-pox,  etc.  That  there  is 
a  close  alliance  between  it  and  epidemic  erysipelas  I  have  no  doubt,  and 
such  are  the  views  entertained  by  most  writers  and  teachers.  It  is  well 
known  that  erysipelas  has  been  occasioned  by  puerperal  fever,  while  on 
the  other  hand  erysipelas  has  given  rise  to  puerperal  fever.  Thus, 
these  two  diseases  may  present  themselves  as  modifications  of  the  same 
morbid  condition  of  the  blood  (putrid  infection),  each  one  presenting 
symptoms  of  a  varied  character,  according  to  the  changes  and  conditions 
resulting  from  age,  character  of  labor,  period  of  attack  after  delivery, 
resisting  power,  temperament,  habits  of  life,  predisposition,  etc.  With 


PUERPERAL    FEVER.  657 

regard  to  the  effects  of  this  same  cause  of  infection,  an  eminent  French 
physician,  who  has  bestowed  considerable  attention  to  its  investigation, 
observes  : 

"  But  this  morbid  influence  once  felt,  the  anatomical  modifications 
which  accompany  it,  having  neither  constancy  nor  fixed  place  of 
election,  it  will  follow  that  these  manifestations  will  be  expressed  by 
the  lesion  of  the  organs  whose  vitality  is  excited,  and  which  their 
irritation  predisposes  to  become  the  seat  of  serious  changes.  In  the 
lying-in  women,  it  will  be  the  lymphatic  vessels  and  veins  of  the 
uterus,  the  uterus  itself  and  peritoneum — hence,  puerperal  fever  with 
its  so  frequent  complications  of  lymphangitis  or  of  uterine  phlebitis, 
of  metritis  and  peritonitis.  In  the  wounded,  in  whom  the  venous  and 
lymphatic  system  is  injured,  it  will  likewise  be  lymphangitis,  erysipe- 
las, and  purulent  absorption.  On  the  subject  whose  skin,  hardly 
excoriated,  presents  but  few  irritated  lymphatics,  it  will  be  lymphan- 
gitis and  erysipelas.  If  we  view  the  local  lesion  in  this  way,  although 
we  recognize  the  anterior  existence  of  the  general  aifection,  which 
alone,  to  speak  truly,  constitutes  the  disease,  we  find  the  explanation 
of  its  most  marked  symptoms,  the  erysipelatous  eruption,  which,  in 
the  women  submitted  to  our  observation,  had  always  for  a  starting 
point  a  slight  solution  of  the  continuity  of  the  skin,"  M.  Pihan- 
Dufeillay, 

Of  late  years  there  have  been  considerable  thorough  and  careful 
researches  as  to  "  the  infective  product  of  all  acute  suppurative  inflamr 
mations,  as  well  as  into  the  distinctive  characters  of  the  noxious  or 
septic,  and  the  innocuous,  bacteria."  Dr.  B.  Sanderson,  of  London, 
England,  in  a  communication  to  the  Pathological  Society  of  London, 
on  pyemia,  observes :  "  I  wish  to  show  (1)  that  every  pyemic  abscesa 
contains  a  poison,  which,  when  introduced  either  into  the  circulation 
or  into  a  serous  cavity,  produces  the  symptoms  of  pyemia;  and  (2) 
that  we  have  this  poison  so  entirely  in  our  possession,  and  so'  far  under 
our  control,  that  beginning  with  an  agent  so  mild  in  its  action  that  it 
produces  no  marked  symptoms,  we  can  convert  it  into  an  agent  of  such 
intensity,  that  it  kills  in  two  or  three  hours,  with 'the  formidable 
symptoms  seen  in  the  case  we  have  now  before  us. 

"  This  intensification  is  effected  by  a  process  which  may  be  called 
cultivation.  Dr.  Klein  made  the  important  discovery,  that,'  if  a 
pyemic  liquid  were  transferred  to  the  peritoneum  of  a  guinea-pig,  and 
allowed  to  remain  there  for  a  couple  of  days,  although  it  did  not  at 
first  produce  any  intense  symptoms  in  the  animal  itself,  its  tox'ic' in- 
tensity increased  in  such  a  degree  that,  when  the  transudation-liquid 
42 


658  KIM;'S  KCLKCTIC  oi',sTirn;ics. 

produced  in  this  was  injected  into  another  animal,  it  had  acquired  the 
most  deadly  activity;  and  that  all  such  extremely  active  liquids  were 
crowded  with  bacteria  of  a  peculiar  character,  the  increased  number 
of  which  seemed  to  be  in  proportion  to  their  toxic  properties."* 

Again,  he  replied  to  remarks,  from  some  of  the  members  of  the 
society,  concerning  the  presence  of  bacteria,  etc.:  "As  regards  bacteria 
in  general,  I  am  well  aware  from  my  own  experiments,  that  the  ordinary 
bacteria  of  putrefaction  possess  no  toxic  action,  and  that  liquids  con- 
taining them  can  be  injected  into  the  circulation  of  living  animals 
without  result.  As  regards  the  bacteria  of  pyemic  products,  I  have 
carefully  guarded  against  the  inference  that  they  were  the  efficient 
causes  of  pyemia.  I  regard  them  as  only  characteristic  inhabitants 
of  infective  liquids,  and  therefore  very  probably  carriers  of  infection. 
As  regards  the  word  septicemia,  I  consider  it  to  mean  a  state  of  the 
blood  which  was  only  present  in  the  most  intense  forms  of  pyemia, 
and  I  agree  with  Mr.  Hulke  in  regarding  metastatic  abscesses  as  an 
accident,  rather  than  as  an  essential  of  pyemic  infection." 

The  malady  occurs  more  frequently,  and  with  greater  malignancy 
in  cold  seasons,  and  during  damp,  or  moist  conditions  of  the  atmos- 
phere, while  in  warm  and  dry  seasons  it  is  less  common,  and  more 
favorable  in  its  results. 

Much  has  been  said  about  the  contagious,  or  non-contagious  char- 
acter of  puerperal  fever;  some  of  our  most  eminent  medical  men 
maintaining  that  it  is  decidedly  contagious,  and  others,  equally  as  dis- 
tinguished, supporting  an  opposite  opinion.  It  is  a  very  difficult 
matter  to  satisfactory  determine  this  question,  because  the  extension 
of  the  disease,  during  its  endemic  existence,  may  be  safely  attributed 
to  its  endemic  nature;  while,  on  the  other  hand,  instances  have 
occurred  which  so  strongly  manifested  a  contagion,  or  an  extension 
without  endemic  influences,  that,  to  say  the  least,  it  would  be  exceed- 
ingly impolitic  to  make  any  positive  declarations  relative  thereto. 
Perhaps,  there  may  be  some  forms  of  this  disease,  as  for  instance  the 
erysipelatous,  which  may  be  communicable,  even  when  it  occurs 
sporadically;  while  other  spontaneous  forms  are,  probably,  never 
contagious  ;  the  subject  requires  still  further  investigation. 

I  can  not,  however,  divest  myself  of  the  opinion,  that  it  is  a  con- 
tagious disease,  especially  the  typhoid  and  erysipelatous  varieties ;  for, 

*  These  microscopic  animalcnlar  or  vegetable  infusoria,  have  been  observed  hv  a 
number  of  observers  in  pyemic  pus  and  blood,  as  micrococci  ;  bacterium  termo  ;  b.  lineola, 
b.  bacillus,'  the  latter  three  due  to  putrefaction. 


PUERPERAL    FEVER.  659 

notwithstanding  the  statements  and  reasonings  of  those  eminent  gen- 
tlemen who  favor  the  side  of  non-contagion,  I  have  witnessed  so  many 
instances  in  which  its  existence  could  be  accounted  for  in  no  other 
way  than  by  contagion,  that  other  explanations  than  those  I  have  met 
with  will  be  required  to  change  my  views  on  this  subject.  Peritonitis, 
metritis,  etc.,  may  exist  at  the  puerperal  period,  independent  of  any 
pyemic  infection,  and  though  they  may  be  modified  to  a  greater  or  less 
degree  by  the  puerperal  condition,  it  does  not  absolutely  render  them 
contagious ;  and  where  these  forms  of  puerperal  fever  exist,  it  is 
possible  the  disease  may  be  non-contagious.  In  the  present  unsettled 
condition  of  this  question,  whatever  may  be  our  opinions,  I  believe 
with  Dr.  R.  Lee,  "  that  it  is  our  duty  to  act  in  all  cases  as  if  the  con- 
tagious nature  of  the  disease  had  been  completely  demonstrated." 
The  accoucheur  who  is  attending  a  case  of  puerperal  fever,  should,  for 
a  season,  avoid  waiting  upon  any  parturient  females ;  he  should  like- 
wise forbid  the  presence  of  pregnant  women  within  the  apartment  of 
his  patient,  as  instances  have  occurred,  where  the  only  assignable 
cause  for  the  attack,  was  the  presence  of  the  female,  during  pregnancy, 
in  the  room  of  a  child-bed  fever  patient.  It  is  likewise  stated  by 
some  authors,  that  a  similar  exposure  of  the  non-pregnant  female, 
during  the  catamenial  period,  has  occasioned  fever  of  a  somewhat 
similar  character. 

As  to  the  contagious  nature  of  fevers  during  the  puerperal  period, 
Prof.  Leishman  calls  attention  to  cases  cited  by  Dr.  Tyler  Smith, 
viz.:  "Two  medical  men,  brothers  and  partners,  attended,  in  the 
space  of  five  months,  twenty  cases  of  midwifery.  Of  these,  fourteen 
were  affected  with  puerperal  fever,  a  fatal  result  ensuing  in  eight 
cases.  The  only  other  known  death  from  puerperal  fever  in  the 
same  town,  within  the  period  named,  occurred  in  the  case  of  a 
patient  attended  by  a  medical  man  who  had  assisted  at  the  post- 
mortem of  one  of  these  puerperal  patients.  After  this  disastrous 
period  the  two  brothers  relinquished  all  their  midwifery  engage- 
ments for  one  month,  in  which  time  five  of  their  cases  were  attended 
by  other  practitioners,  and  no  instance  of  fever  occurred  in  the 
course  of  that  month.  They  then  returned,  and  several  fatal  cases 
again  happened.  Mr.  Robertou,  of  Manchester, 

relates,  perhaps,  one  of  the  most  cogent  instances  of  contagion  and 
fatality  on  record.  In  the  space  of  one  calendar  month,  a  certain 
midwife  attended  twenty  cases  belonging  to  a  lying-in  charity;  of 
t'icso,  sixteen  had  puerperal  fever,  and  all  died.  The  other  mid- 
wives  of  the  sain:;  charity,  working  in  the  same  district,  attended,  in 


C60  KING'.,  ECLECTIC  OBSTETRICS. 

the  same  time,  380  cases,  none  of  whom  were  affected  with  puerperal 
fever.  In  another  large  town,  containing  many  thousands  of  inhab- 
itants and  numerous  medical  men,  fifty -three  cases  of  puerperal  fever 
occurred.  Of  these,  no  loss  than  forty  happened  in  the  practice  of 
one  medical  man  and  his  assistant."  Many  other  instances,  in  sup- 
port of  the  contagious  character  of  this  fever,  might  be  given ;  the 
above,  however,  are  deemed  sufficient. 

The  several  varieties  of  puerperal  fever,  classified  according  to 
the  pathological  conditions  which  are  present,  may  be  described  as 
follows :  * 

1.  Peritonitis,   or   inflammation   of    the    uterine    peritoneum,    and 
peritoneal  sac. 

2.  Inflammation  of  the  uterine  appendages,  as  the  ovaries,  Fallopian 
tubes,  and  ligaments. 

3.  Metritis,  or  inflammation  of  the  mucous,  and  muscular,  or  proper 
tissue  of  the  uterus. 

4.  Uterine  phlebitis,  or  inflammation  and  suppuration  of  the  veins 
of  the  uterine  organs. 

5.  Inflammation  of  the  uterine  absorbents. 

6.  No  primary  inflammation,  but  severe  symptoms  of  a  malignant 
typhoid  nature,  undoubtedly  due  to  absorption  of  putrid  material. 

I.  PERITONITIS,  of  the  lying-in  female,  is  usually,  but  not 
always,  ushered  in  with  rigors,  more  or  less  severe  in  their  character, 
and  which  are  preceded,  accompanied,  or  followed  by  uterine  tender- 
ness, or  pain.  The  rigors  may  be  very  slight,  scarcely  perceived  by 
the  patient,  or  they  may  be  very  violent,  resembling  an  attack  of 
intermittent  fever,  with  coldness  of  the  extremities.  The  pain,  how- 
ever slight  it  may  have  been  at  first,  gradually  increases  in  severity, 
at  the  same  time  extending  itself  over  the  abdomen.  In  the  early 
part  of  the  disease  it  may  be  mistaken  for  after-pains,  but  may  be 
determined  from  them,  by  making  pressure,  during  the  intervals, 
over  the  iliac  and  hypogastric  regions — if  no  pain  or  soreness  is 
produced,  there  is  no  peritonitis.  But  if  the  pain  has  obstinately 
persisted  for  several  days,  with  symptoms  of  constitutional  disturb- 
ance, there  will  be  strong  reasons  for  suspecting  a  lurking  inflamma- 
tion. Commonly,  when  pressure  is  made  over  the  regions  just  named, 
the  patient  being  attacked  with  peritonitis,  will  complain  of  pain. 
Cases,  however,  are  recorded  in  which  the  most  severe  form  of  puer- 
peral peritonitis  existed,  without  any  tenderness  or  pain  in  the 
abdominal  region. 


PUERP-ERAL    FEVER.  661 

The  rigors  pass  away  after  a  short  period,  and  are  followed  by 
febrile  symptoms,  as  flushed  face,  great  heat  of  the  surface,  thirst, 
sometimes  nausea  and  vomiting,  short  and  hurried  respiration,  and  an 
intense  pain  across  the  forehead.  The  pulse,  during  the  rigor,  is 
usually  full,  strong,  and  accelerated,  beating  from  110  to  140  in  a 
minute  ;  but  as  the  disease  progresses,  it  loses  its  hardness  and  volume, 
and  becomes  more  frequent,  small,  and  wiry,  beating  from  130  to  160 
and  upward  in  a  minute ;  and  in  all  cases  when  the  pulse  of  a  puer- 
peral female  remains  persistently  above  100  beats  in  a  minute,  it  is 
good  evidence  of  the  existence  of  some  abnormal  action.  The  tongue 
is  usually  covered  with  a  thin,  moist,  white  or  cream-like  film,  but 
red  at  the  edges;  and  sometimes  the  whitish  film  is  absent,  and  the 
whole  surface  of  the  organ  is  red.  As  the  disease  progresses,  the 
coating  becomes  yellowish  or  brown,  and  occasionally  there  will  be  a 
dryness  of  the  tongue,  with  a  brownish  coat  from  the  commencement. 
The  lochial  discharge  may  be  completely  suppressed,  or  only  lessened 
in  quantity,  and  occasionally  it  continues  to  flow  as  usual.  The  secre- 
tion of  milk  is  most  generally  suspended,  and  the  mammae  become 
flaccid.  The  urine  is  scanty,  turbid,  or  high-colored,  with  more  or 
less  difficulty  in  voiding  it.  Obstinate  constipation  is  ..generally 
present  in  the  early  part  of  the  disease.  The  countenance  of  the 
patient  is  peculiar,  after  the  disease  has  formed  itself  completely, 
presenting  a  ghastly,  pallid,  anxious,  and  suffering  appearance,  with  a 
livid  hue  under  the  eyes.  Sometimes  a  crimson  patch  will  be  observed 
on  one  or  both  cheeks,  which  is  an  unfavorable  symptom. 

At  the  onset  of  the  disease  the  abdomen  is  generally  soft  and 
flaccid,  but  becomes  swollen  and  tympanitic  as  the  disease  advances. 
From  the  commencement  of  the  attack,  any  motion  of  the  lower 
limbs  will  occasion  more  or  less  pain:  when  this  is  severe,  the  patient 
usually  lies  upon  her  back,  with  the  knees  drawn  up  to  the  abdomen; 
which  posture  she  retains  on  account  of  the  pain  caused  by  extending 
them.  The  pain  eventually  becomes  so  intense  that  she  is  unable  to 
bear  the  least  pressure  upon  the  abdomen;  the  bandage  will  have  to 
be  loosened  or  removed  altogether,  and  frequently  the  hands  will  be 
employed  in  holding  up  the  bedclothes  to  remove  their  weight  from 
the  suffering  parts.  The  least  motion,  as  turning  on  one  side,  cough- 
ing, etc.,  occasions  great  suffering,  in  consequence  of  which  she  lies 
remarkably  still,  manifesting  her  distress  and  uneasiness  by  screams 
and  moans,  by  throwing  her  arms  about,  and  occasionally  turning  her 
head  from  side  to  side.  With  the  tympanitic  condition  of  the  abdo- 
men the  pain  will  become  more  aggravated,  or  it  may  entirely  subside. 


KING'S  KCI.IOCTIC  OIJSTKTUICS. 

The  patient  will  frequently  be  indifferent  to  the  welfare  of  her  infant,, 
even  refusing  to  give  it  suck. 

As  the  inflammation  extends  throughout  the  abdominal  organs  the 
tympanitic  condition  of  the  abdomen  increases;  the  vomiting,  which 
was  at  first  mucous  or  bilious  matter,  becomes  green,  brown,  or 
blackish,  like  coffee-grounds;  the  evacuations  become  dark  and  fetid, 
or  a  diarrhea  may  be  present,  which  is  an  unfavorable  symptom ;  the 
skin  becomes  cold  and  clammy;  the  pain  ceases,  an  evidence  that 
effusion  has  taken  place;  if  the  diaphragmatic  peritoneum  has  been 
involved  in  the  inflammation,  hiccough  takes  place.  Generally,  the 
female  retains  her  senses  until  near  the  end  of  the  disease,  when  lo\v. 
muttering  delirium  ensues,  with  carphologia,  or  picking  at  the  bed- 
clothes; the  lips,  hands,  and  feet  become  purple;  the  pulse  gradually 
diminishes,  ceasing  at  the  wrist,  elbows,  and  axillae,  when  death 
speedily  closes  the  scene. 

All  the  symptoms  named  will  not  generally  be  found  in  any  one 
case;  perhaps  the  most  uniform  among  them  is  the  frequent  pulse. 
This,  together  with  rigors,  pains,  vomiting,  and  tympanitis,  are  more 
commonly  observed. 

DIAGNOSIS. — It  is  not  a  very  easy  matter  to  determine  between 
the  varieties  of  uterine  inflammation,  in  puerperal  fever,  as  the  symp- 
toms, in  a  great  measure,  bear  some  resemblance ;  nor,  in  a  practical 
point  of  view,  is  it  of  much  importance,  as  the  treatment  in  each  of 
them,  whether  existing  singly  or  combined,  will  be  nearly  the  same. 
Yet  it  will  be  proper,  notwithstanding,  to  name  some  of  the  distin- 
guishing marks  between  peritonitis  and  other  disorders,  for  which  it 
may  sometimes  be  mistaken. 

It  may  be  determined  from  hysteralgia,  or  after-pains,  by  observing 
that  in  these  there  is  but  little  tenderness  on  pressure  during  the 
absence  of  the  pains;  that  the  uterus  perceptibly  contracts  and  hardens 
when  they  are  present,  which  is  not  the  case  with  the  peritonitic  pain ; 
and  that  the  pains  dimmish  from  day  to  day,  wrhile  that  of  peritonitis 
rapidly  augments.  The  pulse  is  frequent,  in  puerperal  fever,  and  but 
seldom  so  in  hysteralgia;  and  when  this  is  the  case,  unlike  the  pulse 
of  peritonitis,  it  soon  falls  to  a  normal  condition.  In  peritonitis,  the 
disturbance  to  the  general  system  increases  every  day,  while  in  hys- 
teralgia it  gradually  ceases. 

Intestinal  irritation,  from  depraved  secretions  or  fecal  accumulations, 
is  frequently  mistaken  for  puerperal  fever.  The  difficulty  generally 
attacks  at  a  later  period  than  peritonitis,  and  does  not  occasion  so 
much  constitutional  disturbance.  The  pain  in  the  abdomen  is  equally 
diffused,  and  does  not  spread  from  a  focus ;  the  uterus  is  not  tender 


1'EKiTu-Nms  .   G63 

r.or  enlarged;  the  abdomen  is  soft  and  puffy,  not  tympanitic,  nor  does 
pressure  aggravate  the  pain  to  any  extent,  and  the  patient  can  more 
readily  move  in  bed.  In  each  there  may  be  chills,  heat  of  skin,  head- 
ache, rapid  pulse,  loaded  tongue,  flatulence,  nausea,  vomiting,  and 
diarrhea  or  constipation.  Intestinal  irritation  is  said  to  be  frequently 
confounded  with  peritonitis,  and  has  been  supposed  to  be  the  reported 
"violent  cases  of  peritonitis  in  which  the  patient  dies  between  the 
stage  of  excitement  and  of  effusion,  and  no  effusion  or  signs  of  inflam- 
mation are  found." 

In  metritis  or  hysteritis,  but  little  pain  is  produced  on  pressing  the 
abdominal  parietes  until  the  enlarged  uterus  is  touched,  while  in  peri- 
tonitis, the  least  degree  of  pressure  on  the  abdomen  causes  severe 
pain.  The  other  symptoms  of  metritis  are  less  general  than  those  of 
peritonitis. 

POST-MORTEM  APPEARANCES.— The  peritoneum, especially 
that  portion  covering  the  uterus,  is  red,  vascular,  thickened,  and  some- 
times softened,  and  is  frequently  covered  with  a  layer  of  lymph, 
resembling  a  false  membrane,  which  occasions  adhesions  between  the 
omentum  and  intestines,  and  sometimes  between  the  omentum  and 
fundus  uteri.  The  redness  will  be  the  more  intense,  and  the  thicken- 
ing of  the  peritoneum  the  greater,  in  proportion  to  the  duration  of 
the  pain  and  the  severity,  of  the  disease.  The  omentum  frequently 
exhibits  marks  of  inflammation,  being  red  and  highly  vascular;  and 
this  may  be  found  without  any  evidences  of  inflammation  of  the  peri- 
toneum. The  serous  coverings  of  the  several  organs,  in  the  cavity 
of  the  abdomen,  may  exhibit  evidences  of  inflammatory  action.  .  A 
turbid,  whey-colored,  or  red  serum,  with  purulent  or  albuminous 
shreds  floating  in  it,  or  a  yellowish  lymph,  are  effused,  in  greater  or 
smaller  quantity,  into  the  peritoneal  cavity,  and  sometimes  blood  will 
be  found,  alone,  or  mixed  with  the  serous  fluid.  Pus  is  frequently 
found  deposited  behind  and  around  the  uterus,  beneath  its  peritoneal 
covering,  and  at  those  points  where  the  inflammation  has  appeared  to- 
be  the  most  active. 

II.  INFLAMMATION  OF  THE  UTERINE  APPENDAGES, 

may  exist  in  conjunction  with  inflammation  of  the  peritoneal  covering' 
of  the  uterus,  or  it  may  occur  entirely  independent  of  it:  more  fre- 
quently, however,  they  are  met  with  together,  and  when  this  happens, 
the  symptoms  common  to  peritonitis  will  be  present,  with  the  addition 
of  those  which  belong  to  inflammation  of  the  appendages. 

When  the  serous  membrane  and  proper  tissue  of  the  ligaments, 
Fallopian  tubes  and  ovaries  are  attacked  with  inflammation,  while  the 


6G4  KING'S  KCLKCTIC  OBSTETRICS. 

peritoneal  sac  is  but  slightly  affected,  or  not  at  all,  the  pain  will  he 
located  principally  in  one  of  the  iliac  fossae,  extending  from  thence  to 
the  groins,  anus,  and  down  the  thighs.  On  making  pressure,  the  pain 
will  be  experienced  in  the  lateral  portions  of  the  hypogastrium,  and 
will  be  less  intense  than  in  general  peritonitis.  An  examination  per 
vaginara  will  find  the  upper  part  of  this  canal  hot  and  painful.  The 
constitutional  symptoms  are.  similar  to  those  of  peritonitis,  as  rigors, 
hot  skin,  thirst,  headache,  frequent  pulse,  etc.  When  the  attack  is 
severe,  prostration  takes  place  rapidly,  and  the  disease  may  speedily 
prove  fatal.  Or,  it  may  terminate  in  resolution,  without  injury  to  the 
organs;  with  obliteration  of  one  or  both  of  the  Fallopian  tubes;  or 
with  adhesions  between  the  tubes  and  parts  in  proximity,  or  of  por- 
tions of  serous  membrane,  and  which  may  subsequently  prove 
injurious. 

Or,  it  may  terminate  in  suppuration,  matter  being  formed  in  the 
ligament  or  ovaries,  and  escaping  into  the  peritoneal  sac ;  through  the 
vaginal  or  rectal  walls;  or,  through  the  walls  of  the  abdomen  in  the' 
neighborhood  of  Poupart's  ligament. 

POST-MORTEM  APPEARANCES.— The  surface  of  the  Fal- 
lopian tubes,  ovaries,  and  broad  ligaments,  are  red  and  vascular,  and 
are  imbedded  to  a  greater  or  less  extent  in  pus  or  lymph.  The 
fimbriated  extremities  of  the  tubes  are  of-  a  deep-red  color,  and  fre- 
quently softened,  and  diffused  or  circumscribed  deposits  of  pus  may 
be  observed  beneath  their  coverings,  and  in  their  cavities.  Effusions 
of  pus  or  serum  may  likewise  be  found  between  the  folds  of  the  broad 
ligaments,  and  small  masses  of  pus  will  be  met  with,  dispersed 
throughout  the  enlarged  ovaries ;  or  these  organs  may  be  converted 
into  a  cyst  holding  pus,  which  escapes  through  ulcerated  openings. 
One  or  both  of  the  ovaries  may  exhibit  evidences  of  inflammatory 
action,  their  peritoneal  coat  being  red,  vascular,  and  imbedded  in 
lymph.  They  may  be  greatly  enlarged,  swollen,  red,  and  pulpy,  or 
there  may  be  no  apparent  change  in  their  parenchymatous  structure. 
On  dividing  the  ovaries,  a  great  augmentation  of  vascularity  will  be 
seen,  with  a  softening,  or  complete  disorganization  of  its  proper  tissue. 
Occasionally,  there  will  be  an  effusion  of  .blood  into  the  Graafian 
vesicles,  destroying  their  texture. 

III.  METRITIS,  HYSTERITIS,  or  INFLAMMATION  OF 
THE  UTERUS,  commences  most  commonly  on  the  third  or  fourth 
day  after  delivery,  usually,  but  not  invariably,  with  rigors,  followed 
by  a  hot  and  dry  skin,  thirst,  headache,  accelerated  pulse,  dry  and 


METRITIS — UTERINE    PHLEBITIS.  665 

furred  tongue,  with  pain  and  tenderness  in  the  uterine  region,  though 
pressure  upon  the  abdomen  occasions  no  pain  until  the  hard  and 
enlarged  uterus  is  reached.  The  abdomen,  at  first  soft,  becomes 
tympanitic,  and  if  the  proper  remedies  are  withheld  the  inflammation 
may  extend  to  the  peritoneum,  when  the  pain  will  spread  over  the 
abdomen,  being  attended  with  the  symptoms  peculiar  to  peritonitis. 
The  lochial  discharge  may  be  diminished  or  suspended,  and  mav 
remain  unchanged,  or  become  of  a  dark  color,  and  very  fetid.  Thr 
secretion  of  milk  is  generally  defective;  the  urine  is  scanty,  occasion- 
ing much  pain  when  voided.  A  vaginal  examination  will  find  the 
os  uteri  very  hot  and  tender. 

In  the  more  severe  attacks,  the  above  symptoms  will  exist  in  an 
augmented  degree,  with  a  pale  countenance  expressive  of  pain  and 
great  anxiety.  The  skin  frequently  becomes  cold,  assuming  a  sallow 
or  bluish  tinge.  The  pulse  becomes  rapid  and  feeble;  the  respiration 
hurried  and  distressing,  with  excessive  prostration  of  strength.  The 
pulse  is  more'feeble,  and  the  patient  becomes  more  speedily  prostrated, 
than  in  peritonitis. 

If  the  disease  progresses  without  amelioration,  the  tongue  becomes 
coated  with  a  dark  or  brown  fur;  the  teeth  and  lips  covered  with 
'sordes;  the  extremities  become  cold,  with  cold  and  clammy  perspira- 
tion; vomiting  is  most  usually  present  and  also  an  obstinate  diarrhea, 
the  strength  fails  rapidly,  with  coma,  or  low  muttering  delirium, 
subsultus  tendinum,  and  death.  Metritis  may  terminate  in  resolution, 
abscess,  softening,  or  gangrene ;  the  milder  varieties  in  the  first- 
named,  and  the  more  severe  in  one  of  the  latter. 

POST-MORTEM  APPEARANCES.— The  uterus  will  be  found 
» 

enlarged,  and  its  substance  soft  and  flabby,  presenting  a  dark  purple, 
grayish,  or  yellowish  pulp,  sometimes  of  a  very  offensive  odor,  and 
which  may  exist  in  patches,  or  occupy  a  large  tract  of  the  organ. 
The  softening  generally  proceeds  from  the  inner  uterine  surface,  and 
extends  through,  involving  the  peritoneal  covering.  Frequently 
there  will  be  extensive  disorganization  of  the  muscular  tissue  of  the 
uterus,  without  any  change  in  the  character  of  the  peritoneal  coat. 
All  parts  of  the  uterus  may  be  attacked  by  inflammation  and  soften- 
ing, and,  frequently,  that  portion  to  which  the  placenta  was  attached 
is  alone  found  to  be  disorganized.  Coagulable  lymph  forming  false 
membranes,  and  mixed  with  blood,  and  lochia,  are  also  found  on  the 
inner  mucous  membrane;  and  in  a  few  instances,  instead  of  a  com- 
plete disorganization  of  the  muscular  tissue  of  the  uterus,  small 
-abscesses  containing  pus  have  been  found  in  this  tissue. 


666  KING'S   i-;<  I,K<  TI<    <>];STKTRICS. 

The  peritoneum,  covering  the  inflamed  part  of  the  muscular  coat 
of  the  uterus,  very  o,ften  presents  evidences  of  inflammatory  action ; 
it  may  be  red,  yellow  or  livid,  having  a  disposition  of  lymph  on  its 
imrface,  or  without  this,  but  so  softened  in  its  texture  as  to  be 
readily  torn. 

IV.  UTERINE  PHLEBITIS,  or  inflammation  of  the  veins  of  the 
uterus,  may  be  produced  by  any  of  the  Causes  that  occasion  the  other 
forms  of  puerperal  fever.  The  symptoms  are  similar  to  the  preceding 
attacks,  as  rigors  succeeded  by  hot  skin,  thirst,  accelerated  pulse 
headache,  etc.,  together  with  pain  in  the  uterine  region,  which  is  much 
increased  on  pressure,  and  a  suppression  of  both  the  lochial  discharge 
and  the  secretion  of  milk.  Frequently  a  confusion  of  mind,  or  inco- 
herency  will  be  observed. 

The  disease  progresses  very  rapidly,  the  symptoms  augmenting  in 
intensity;  rigors  will  frequently  be  present,  especially  during  the 
early  part  of  the  attack,  succeeded  by  an  increased  heat  o-f  the  surface, 
the  tongue  becomes  dry  and  brown,  with  insatiable  thirst,  rapid,  full 
pulse,  hurried  respiration,  vomitings  of  a  greenish  fluid,  tremors  of 
the  muscles  of  the  face  and  extremities,  excessive  drowsiness,  or  violent 
delirium.  The  body  becomes  of  a  deep  sallow  color,  and  sometimes* 
petechise,  or  vesicular  eruptions  will  be  seen  on  various  parts  of  it. 
The  abdomen  is  frequently  swollen  and  tympanitic,  and  the  tenderness 
in  the  uterine  region  is  increased;  occasionally,  no  pain  is  present. 

Death  may  take  place  during  the  acute  stage,  or  the  patient  may 
recover  from  the  primary  attack  and  have  her  life  shortened  by  sec- 
ondary affections  of  the  other  parts,  as  for  instance :  congestion  of  the 
vessels  of  the  brain,  and  deposition  of  lymph  or  serum  into  the  ven- 
tricles; arachnitis;  softening  of  portions  of  the  brain;  or  deposit  of 
pus  into  the  cerebral  substance.  Congestions  of  the  lungs,  or  disor- 
ganization of  their  substance;  pleuritis;  effusions  of  serum  or  blood; 
gangrene,  etc.  Hypertrophy  of  the  heart  with  softening,  and  occa- 
sionally depositions  of  lymph  and  serum  in  the  pericardium.  Inflam- 
mation and  softening  of  the  mucous  coat  of  the  stomach;  effusions 
of  reddish  serum  between  its  mucous  and  muscular  tissues.  Softening 
and  perforation  of  portions  of  the  intestines.  Congestion,  softening, 
or  abscess  of  the  liver,  or  of  the  spleen.  Inflammation  of  the  kidneys, 
with  depositions  of  pus,  softening,  etc.  Inflammation  of  the  conjunc- 
tiva, with  effusion  of  lymph  in  the  anterior  chamber,  destroying  sight. 
Inflammation  of  the  joints,  with  abscess,  and  infiltration  of  a  sero- 
sanguineous  'fluid  into  the  muscles  or  cellular  substance  of  the  limbs,. 


TRITE    PUERPERAL    FEVER.  667 

presenting  the  appearance  of  erysipelas.  Sometimes  abscesses  form 
discharging  enormous  quantities  of  pus,  rapidly  prostrating  the  patient. 

DIAGNOSIS. — This  is  very  difficult  to  distinguish  from  the  pre- 
ceding varieties,  especially  during  its  early  stage.  The  pain  and 
tenderness  is-  more  confined  to  one  spot  than  in  peritonitis,  and  when 
the  disease  has  continued  for  some  time,  the  secondary  affections  will 
manifest  themselves. 

POST-MORTEM  APPEARANCES.— The  uterine  veins  are  found 
changed,  having  their  coats  thickened,  and  their  canals  frequently  so 
closely  contracted  as  to  be  almost,  if  not  quite  impervious;  and  their 
lining  membrane  will  be  pale  and  covered  with  lymph  or  pus,  fre- 
quently it  will  be  of  a  bright  scarlet  color.  Similar  conditions  will 
be  found  when  distant  veins  are  involved,  with  a  hardening  of  the 
surrounding  cellular  tissue,  which  contains  depositions  of  pus.  Most 
commonly  the  inflammation  is  confined  to  the  veins  of  one  side  only, 
and  which  is  the  side  corresponding  with  that  of  the  placental  attach- 
ment. Occasionally  the  veins  will  be  plugged  up  with  firm  coagula, 
or  other  abnormal  substances.  Beside  the  uterine  veins,  the  spermatic 
are  more  frequently  affected — and  the  disease  may  extend  rapidly  to 
the  hypogastric  veins.  The  renal  veins  are  generally  involved,  with 
a  soft  and  vascular  condition  of  the  substance  of  the  kidney. 

V.  INFLAMMATION  OF  THE  UTERINE  ABSORBENTS, 
or  LYMPHATICS,  presents  all  the  symptoms  common  to  uterine 
phlebitis,  from  which  it  is  almost  impossible  to  distinguish  it.     It  is 
likewise  followed  by  secondary  affections  similar  to  that  disease. 

POST-MORTEM  APPEARANCES.— Pus  is  found  at  different 
points  of  the  lymphatics,  generally  at  nearly  regular  intervals,  pre- 
senting a  beaded  appearance. 

VI.  NO   PRIMARY  INFLAMMATION,  TRUE   PUERPE- 
RAL SEPTICEMIA,  or  PYEMIA,  in  the  more  severe  degrees  of 
which  the  vital  powers  rapidly  fail,  and  death  occurs  before  inflam- 
mation has  had  an  opportunity  to  manifest  itself.     It  is  ushered  in, 
within  a  few  days  succeeding  delivery,  with  violent  rigors,  or  with  a 
peculiar,  chilly  sensation,  greatly  increased  temperature,  varying  from 
100°  to  108°,  quick  and  small  pulse,  96    to  150,   and  extreme  depres- 
sion of  the  vital  powers  ;  not  unfrequently  an  offensive  diarrhea  will 
come  on  within  from  twelve  to  thirty-six  hours  from  the  commencement 
of  the  attack,  and  at  a  later  period,  say  in   from  twenty-four  to  forty- 
eight  hours,  dyspnoea  may  appear,   being  due  probably  to  the  blood 
globules  having  lost  the  property  of  complete  hematosis.     The  face- 


068  KING'S  KCU-XTI.'  OUSTKTIIICS. 

becomes  pale  with  an  expression  of  anxiety,  and  the  features  pinched 
and  sunken;  headache  is  frequent,  with  nervous  prostration  and  mental 
indifference,  the  patient  seldom  complaining  or  even  evincing  an  inter- 
est in  her  condition.  The  speech  and  movements  of  the  patient  are 
tremulous;  the  mind  is  clear  during  the  day,  but  at  night-,  there  will 
often  be  observed  a  kind  of  suhdelirium,  however,  without  agitation. 
The  breath  is  more  or  less  fetid;  the  tongue  dry  and  fuliginous:  the 
skin  becomes  covered  with  a  cold,  clammy  perspiration  :  the  muscles 
flabby  and  enfeebled,  with  suppression  of  the  lacteal  secretion,  as  well 
as  of  the  lochial  flow.  Sometimes,  but  not  always,  there  are  abdom- 
inal pains;  more  commonly  tympanitis ;  and  frequently  vomiting  of 
a  greenish  substance.  The  urine  is  scant,  high  colored,  containing  an 
excess  of  urates,  and,  frequently,  albumen.  The  extremities  and 
trunk  become  more  or  less  covered  with  purplish  spots.  Prostration 
rapidly  ensues,  the  mind  begins  to  wander,  with  drowsiness,  speedily 
followed  by  death  on  the  third  or  fourth  day  from  the  first  manifes- 
tations of  illness. 

All  these  symptoms  are  not  invariably  present,  but  will  vary  with 
different  individuals,  from  a  mild  "  milk  fever,"  to  one  of  the  most 
malignant  character.  Chills  are  frequently  absent  in  this  form  of  the 
affection,  as  in  the  others;  and  even,  pain,  abdominal  tenderne-s.  or 
tympanitis,  may  not  exist,  even  in  those  instances  in  which  the  sep- 
ticemic  form  is  associated  with  severe  peritonitis.  The  malady  may 
exist  merely  as  a  blood  disease,  or,  it  may  be  associated  with,  and 
modified  by,  the  existence  of  one  or  more  of  the  preceding  named 
inflammatory  lesions. 

M.  A.  D'Espine,  who  has  devoted  considerable  attention  to  this 
malady,  gives  the  following  conclusions: 

"  1.  Puerperal  septicemia  is  constituted  by  a  series  of  symptoms 
more  or  less  severe,  according  to  the  dose  of  septic  material  absorbed 
by  wounds  on  the  walls  of  the  utero-vaginal  canal. 

"  2.  These  symptoms  present  nothing  that  is  special  to  the  puerperal 
condition,  and  may  be  assimilated  to  those  which  are  caused  by 
septicemia  in  wounded  subjects  and  in  animals. 

"  3.  The  starting  point  is  always  in  the  uterus  or  vagina ;  all  the 
causes  which  prevent  cicatrization  of  the  uterine  wound  and  which 
favor  the  development  of  septic  materials  on  its  surface,  are  efficient 
causes  of  puerperal  septicemia. 

"4.  The  lymphatics  are  the  habitual  road  of  the  absorption  of  the 
poison;  lymphangitis  is  the  usual  but  not  a  necessary  indication  .of 
its  passage. 


TKL'E  PUERPEKAL  FEVEK.  669 

^5.  Peritonitis  is  an  associated  lesion  due  to  the  transmission  of 
septic  material  by  the  uterine  lymphatic  vessels;  it  may  be  compared 
to  the  local  inflammations  which  are  developed  around  infected  wounds. 

"6.  The  effect  of  septic  absorption  on  the  organism  is  to  determine 
congestions  and  inflammations  in  all  organs,  especially  the  lungs,  kid- 
neys, and  intestines ;  subserous  ecchymoses  or  interstitial  apoplexies, 
internal  or  external  inflammations  localized  by  preference  in  serous 
membranes ;  during  life  this  action  is  manifested  by  fever,  diarrhea, 
pulmonary  congestion,  epistaxis,  and  often  by  temporary  cutaneous 
eruptions. 

"7.  Purulent  absorption  and  septic  absorption^  may  be  confounded 
by  the  bedside. 

"  8.  There  is  no  such  affection  as  milk  fever;  the  fever  of  the  first  ' 
week  is  almost  always  a  slight  septicemia,  due  to  an  absorption  of  the 
lochia,  by  small  wounds  on  the  walls  of  the  utero-vaginal  canal. 
When  the  uterus  does  not  contract,. and  the  lochia  remain  fetid,  this 
fever  may  persist  for  some  weeks.  In  cases  of  this  kind  one  may 
almost  always  find  ulcers  in  the  neck  or  vagina. 

"  9.  These  slight  infections  are  often,  but  not  always,  accompanied 
by  uterine  angioleucitis  and  signs  of  mild  perimetritis.  When  the 
infection  is  prolonged,  it  may  lead  to  consumption  and  death  (septic 
phthisis). 

"  10.  Puerperal  pyemia  is  a  complication  of  septicemia,  and  almost 
always  coincides  with  suppuration  in  the  veins  of  the  uterus. — This 
complication,  which  is  relatively  rare,  is  due  in  all  probability  to  septic 
emboli.  Visceral  metastatic  abscesses  are  tributary  to  this,  whilst  all 
inflammations  of  the  cellular  tissue  and  of  the  articulations  are  due  to 
lymphatic  infection,  and  are  not  embolic  in  their  nature."  Archiv* 
Gen.  de  Medicine,  October,  1872. 

POST-MORTEM  APPEARANCES.— No  peculiar  anatomical 
lesions  belong  to  this  affection.  They  will  vary  from  a  scarcely  notice- 
able softening  of  the  lungs,  liver,  spleen,  or  kidneys,  or  a  few  weak 
adhesions,  etc.,  probably  resulting  from  the  poisoned  and  innutritions 
condition  of  the  blood,  to  the  more  severe  and  extensive  pathological 
appearances  heretofore  referred  to  under  the  various  inflammatory 
conditions  with  which  it  may  be  associated.  The  character  of  the 
post-mortem  lesions  being  due  to  the  degree  and  extent,  of  the  blood- 
poisoning,  the  organs  affected  by  it,  and  the  degree  and  extent  of  the 
inflammatory  lesions  with  which  it  may  be  associated.  The  lesion  will 
often  be  found  in  the  uterine  veins,  the  mouths  of  which  become 


670  KIN(i's    KCLKCTIC    olJSTKTUlr.S. 

plugged  up  by  little  thrombi,  the  decomposition  of  which,  during  life, 
occasioned  the  constitutional  disturbance.  Again,  these  may  be  absent, 
but  the  uterus  itself  will  be  found  in  a  state  of  gangrenous  degenera- 
tion ;  or  the  pleural  and  pericardial  cavities  may  contain  purulent  or 
aero-purulent  deposits.  The  eyes  of  the  patient  have  even  suffered 
with  pain,  suppuration,  and  corneal  rupture ;  and,  when  death  hu.- 
nct  taken  place  so  rapidly  as  usual,  secondary  abscesses  have  been 
found  in  various  parts  of  the  body. 

It  must  be  borne  in  mind,  however,  that  the  lesions  observed  are 
not  the  original  cause  of  the  disease,  but  are  the  results  of  the  poison 
occasioning  it ;  andVvhen  this  poisoning  is  intense,  death  may  occur 
so  suddenly  that  the  pathological  conditions,  which  have  been  supposed 
to  constitute  the  disease,  have  not  had  time  to  develop  themselves. 
Again,  severe  peritonitis,  phlebitis,  etc.,  may  occur  at  the  puerperal 
period,  or  previous  to  it,  independent  of  any  poisonous  absorption, 
the  symptoms  being  more  or  less  modified  by  the  condition  of  the 
puerperal  patient. 

PROGNOSIS. — These  several  varieties  of  puerperal  fever  may 
exist  singly  or  combined,  more  frequently  the  latter ;  and  as  their 
symptoms  so  closely  resemble  each  other,  when  combined  it  will  be  a 
difficult  matter  to  positively  distinguish  between  them,  yet  in  a  prac- 
tical view,  as  before  related,  this  is  of  minor  importance,  the  treatment 
being  the  same. 

The  prognosis  is  always  unfavorable,  and  especially  when  the  disease 
occurs  endemically.  The  most  unfavorable  symptoms  are  suppression 
of  the  lochia,  tympanitis,  delirium,  vomiting  of  greenish,  or  "coffee- 
ground"  substances;  rapid  prostration  of  the  vital  forces;  very  high 
pulse,  or  thready  and  fluttering;  hiccough;  diminished  pain  on  pres- 
sure, with  increased  ability  to  move  the  legs,  and  a  frequent,  feeble 
pulse,  evidencing  that  the  inflammation  has  terminated  in  effusion  ; 
cold,  clammy  skin;  diarrhea,  or  involuntary  stools;  and  dilated  pupils. 
The  most  fatal  period  is  during  the  third  or  fourth  clay. 

But  if,  with  an  ability  of  the  patient  to  move  herself  in  bed,  we 
find  the  pulse  to  lessen  in  frequency,  the  skin  to  become  cooler  and 
softer,  the  thirst  gradually  diminishing,  the  tongue  cleaning,  the  bowels 
being  more  easily  acted  upon,  the  clearness  of  the  skin  returning,  and 
•the  patient  more  able  to  make  a  deep  inspiration,  and  to  obtain  refresh- 
ing sleep,  we  may  augur  favorably.  The  ability  to  change  position 
without  much  pain,  is  frequently  one  of  the  first  symptoms  of  improve- 
ment. Yet,  even  with  all  these  favorable  indications,  we  must  not 


TREATMENT  OF  PUERPERAL  FEVER.  671 

cease  in  our  close  attentions  to  the  patient,  for  it  has  happened,  that 
when  there  was  every  indication  of  a  favorable  result,  and  physicians 
and  friends  were  congratulating  each  other  relative  thereto,  that  the 
symptoms  have  returned  with  increased  severity,  and  the  attack  has 
terminated  fatally. 

TREATMENT.— It  is  seldom  that  puerperal  fever  has  exactly  the 
aame  features,  each  endemic  presenting  symptoms  peculiar  to  itself. 
If  we  admit  only  the  five  varieties  of  the  disease,  as  described  above, 
and  which  may  occur  separately,  or  in  various  combinations  with  each 
other,  we  have,  then,  twenty-six  different  modes  of  manifestation,  in 
which  there  will  be  a  great  diversity  of  symptoms,  in  number,  char- 
acter, and  severity.  But,  when,  as  is  frequently  the  case,  it  prevails 
simultaneously  with  malignant  erysipelas,  or  blood-poisoning,  we  may 
then  have  an  additional  number  of  twenty-six,  giving  to  us  fifty-two 
different  features  which  the  disease  may  present;  and,  probably,  this 
fact  may  lead  us  to  suspect  the  reason  why  writers  have  given  such 
varied  descriptions  of  it,  as  having  occurred  under  their  respective 
observations. 

However  formidable  a  disease  may  at  first  appear,  which  is  capable 
of  presenting  so  great  a  number  of  differences  in  its  features,  yet,  for 
practical  purposes,  they  may  be  reduced  to  two  conditions,  viz.:  that 
in  which  the  inflammatory  symptoms  predominate,  and  that  in  which 
the  typhoid  symptoms,  or,  symptoms  of  blood-poisoning  prevail.  And 
the  treatment  must  be  governed  by  the  presence  of  one  ,pr  the  other 
of  these  conditions.  The  most  important  object  is,  to  eliminate  from 
the  system,  or  to  neutralize  the  absorbed  poison,  as  much  as  possible; 
to  sustain  the  vital  forces ;  and,  in  the  inflammatory  varieties,  to  over- 
come the  congestion  and  inflammation  of  the  parts  attacked,  and  bring 
about  resolution — for  if  the  disease  terminates  in  effusion,,  the  woman 
almost  certainly  dies.  , 

In  the  INFLAMMATORY  FORMS  of  puerperal  fever,  agents 
to  control  the  heart's  action  and  lower  the  temperature,  and  thus 
subdue  the  local  inflammation,  should  be  at  once  administered.  The 
bowels  are  usually  constipated  in  the  beginning,  -and  the  administra- 
tion of  such  means  as  will  properly  overcome  this  condition  should  bo 
thought  of.  Mild  but  efficient  measures  should  always  be  selected.  Tho 
compound  powder  of  Jalap  will  answer  in  some  cases;  a  teaspoonful 
of  the  compound  dissolved  in  two  tablespoonfuls  of  boiling  water, 
sweetened,  and  taken  as  a  dose,  will  usually  give  the  desired  effect. 
The  Cascara  Cordial  is  preferred  by  some  physicians.  All  measures 
that  occasion  depression  of  the  system  should  be  avoided;  under 


672  KING'S  ECLECTIC  OBSTETRICS. 

some  circumstances  it  will  be  better  to  use  enemas,  soliciting  one 
evacuation  daily  in  this  way.  The  bed-pan  should  always  be  used, 
and  the  patient  not  allowed  to  either  get  up  in  bed,  or  out  of  it;  in- 
deed, it  is  much  better  for  her  to  keep  in  the  recumbent  posture,  and 
without  elevating  the  head  and  shoulders  by  pillows. 

It  will  not  be  necessary  to  wait  for  the  catharsis,  but  endeavor  to 
get  the  patient  as  soon  as  possible  under  the  influence  of  such  agents 
as  may  be  specifically  indicated.  If  much  pain  be  present  with  the 
fever,  Aconite  and  Macrotys  should  be  thought  of,  administered  in 
the  usual  small  dose.  The  Sp.  Tr.  of  Veratrum  Viride  is  likewise 
very  useful,  and  when  the  pulse  is  full  and  bounding,  will  be  found 
superior  to  any  other  agent  for  controlling  vascular  excitement,  reduc- 
ing the  pulse  from  120  or  140  to  80  or  100;  it  may  be  administered 
in  doses  varying  from  one- half  to  one  drop,  repeated  every  hour  or 
two,  until  it  has  produced  the  desired  effect;  after  which  it  must  be 
continued,  if  necessary,  in  such  doses,  and  at  such  intervals,  as  may 
be  required  to  keep  the  pulse  reduced.  It  may  be  used  either  singly 
or  in  combination  with  other  agents  that  may  be  called  for. 

With  the  high  grade  of  inflammation,  the  indication  for  Gelsemium 
frequently  stands  out  prominently,  when  it  should  be  administered 
with  the  proper  sedative,  and  will  be  found  to  answer  a  good  purpose. 

Phytolacca  will  be  often  called  for  in  this  disease  also;  it  may  be 
given  in  alternation  with  the  Macrotys  and  sedative.  It  favors  the 
return  of  th^ suppressed  lochia,  and  decidedly  beneficial  results  will 
usually  be  found  to  follow  the  administration  of  these  agents,  and  in 
some  cases  no  other  treatment  will  be  called  for. 

I  frequently  administer  Chlorate  of  Potassium  in  puerperal  fever, 
and  with  good  results.  It  is  indicated  by  the  disagreeable  smell  of 
the  discharges,  and  bad  smelling  breath.  It  can  be  used  in  conjunc- 
tion with  other  agents,  or  may  be  given  in  from  two  to  five-grain 
doses,  singly,  two  or  three  times  a  day. 

Equal  parts  of  the  tinctures  of  Digitalis  and  Stramonium,  given  in 
doses  of  five  or  ten  drops,  every  hour  or  two,  have  frequently  been  of 
advantage  in  this  disease,  particularly  when  the  attack  was  mild. 

Fomentations  applied  over  the  abdomen,  as  hot  as  can  be  borne, 
will  be  found  a  powerful  means  for  relieving  the  pain  and  soreness  in 
that  region  when  due  to  inflammatory  action ;  they  ma'y  be  made  of 
Hups  and  Tansy,  or  Hops  and  Poppy-heads,  or  either  of  these  with 
Chamomile  flowers,  and  they  should  be  renewed  frequently,  not 
permitting  them  to  remain  on  when  cool,  and  the  patient  should  not 


TREATMENT  OF  PUERPERAL,  FEVER.  673 

be  made  uncomfortable  by  applying  them  so  wet  as  to  dampen  the 
bed  upon  which  she  lies.  For  a  fomentation  to  the  bowels  I  know 
of  no  agent  equal  to  the  leaves  of  Stramonium,  which  are  now  being 
used  in  various  inflammatory  affections,  by  some  of  my  colleagues, 
upon  my  recommendation,  and  with  much  success ;  I  have  used  these 
when  fresh,  by  bruising  and  warming  them  previous  to  their  applica- 
tion, or,  by  steeping  the  dried  leaves  in  boiling  water,  and  frequently 
changing  them  upon  the  abdomen.  I  have  persisted  in  the  appliance 
of  this  remedy  even  after  it  has  caused  double  vision  and  other 
symptoms  of  its  peculiar  narcotic  influence  upon  the  system,  and 
invariably  with  benefit.  It  not  only  lessens  pain,  but  actually  assists 
in  reducing  the  inflammatory  action.  When  its  effects  upon  the 
system  are  no  longer  desirable,  one  of  the  previously  named  fomenta- 
tions may  be  substituted.  The  fomentations  will  prove  beneficial  only 
during  the  acute  stage,  and  must  be  dispensed  with  when  prostration 
ensues,  or  when  the  inflammation  has  been  overcome.  The  addition 
of  Oil  of  Turpentine  to  them,  when  tympanitis  is  present,  has  been 
found  useful. 

For  a  common  drink  the  patient  may  take  an  infusion  of  Peach- 
leaves,  which  will  occasion  diuresis,  and  thus  aid  in  lessening  the 
severity  of  the  attack;  this  may  be  drank  freely,  especially  in  the 
early  part  of  the  attack.  A  free  action  of  the  kidneys  is  always 
desirable  in  this  malady,  and  should  be  kept  up  as  much  as  possible, 
as  it  not  only  aids  in  allaying  vascular  excitement,  but  also  affords  a 
means  of  eliminating  the  absorbed  poison  from  the  blood.  In  the 
latter  part  of  the  disease,  other  remedies  will  be  called  for  by  the 
condition  of  the  tongue.  A  good  condition  of  the  stomach  is  neces- 
sary, in  all  eases,  for  the  reception  and  absorption  of  medicines,  and 
assimilation  of  food. 

The  dirty  tongue  is  a  very  common  condition  in  this,  disease,  as 
might  be  expected  from  the  poisoned  state  of  the  blood  following  the 
absorption  of  putrid  material,  together  with  the  high  fever,  nausea 
and  vomiting,  and  inability  to  take  food.  Sulphite  of  Soda  should 
here  bj  given;  a  teaspoonful  every  two  hours  of  a  solution  of  %  i  to 
Water  ^iv,  and  continued  until  the  tongue  cleans  and- the -patient  no 
longer  complains  of  a  bad  taste. 

Another  case  may  present  the  heavily  coated  tongue  ,a.t.,base,  yellow 
appearance  of  the  skin,  fullness  of  the  superficial  veins.  Here 
Podophyllin  should  be  thought  of;  one  grain  triturated  with  one 
hundred  grains  of  Sugar  of  Milk,  and  given  in-  fiVe-grain  doses  two 
or  three  times  a  day,  usually  answers  a  very  good  purpo.se.v'  *.. 
43 


674  KING'S  ECLECTIC  OBSTETRICS. 

The  broad  and  flabby  tongue,  showing  the  imprint  of  the  teeth  on 
the  sides,  calls  for  Lobelia,  which  .should  be  administered  with  the 
sedative,  or  such  other  agents  as  are  being  used. 

The  elongated,  red,  and  contracted  tonr/ue,  evidence  of  irritation,  is 
an  indication  for  Ipecac,  and  it  .should,  as  a  rule,  be  administered 
with  Aconite. 

There  are  numerous  other  remedies  that  will  be  found  valuable  in 
this  affection.  We  should  have  the  case  well  in  hand,  carefully  study- 
ing out  the  condition  and  symptoms  present,  supplying  the  remedies 
in  each  individual  case  according  to  the  specific  indications  present. 
Rhus  Tox,  Bryonia,  Dioscorea,  Baptisia,  Muriatic  Acid,  Sulphurous 
Acid,  are  all  agents  to  be  thought  of  in  connection  with  puerperal 
fever,  and  should  be  given  when  indicated. 

Rhus  Tox,  when  the  sharp  pain  in  frontal  region,  burning  pain  over 
left  orbit,  sharp  stroke  of  pulse,  are  prominent  symptoms,  will  be  the 
Vemedy.  Dioscorea  is  especially  useful  in  subduing  the  pain  of  puer- 
peral peritonitis,  and  may  be  given  with  the  sedative.  When  the 
tongue  becomes  coated  dark,  brown,  or  yellow,  Muriatic  Acid  should 
be  prescribed,  using  a  few  drops  in  a  half-glass  of  water,  enough  to  make 
it  pleasantly  acid,  and  allow  the  patient  to  take  a  teaspoonful  every 
hour  or  two.  Acidulous  draughts  are  also  desirable,  as  lemonade, 
tamarind- water,  orange-juice,  vinegar,  and  even  tart  cider,  when  there 
is  prostration.  If  the  patient  during  the  early  days  of  the  fever  de- 
sires ice,  or  iced  water,  they  should  not  be  withheld. 

When  the  pain  is  very  severe,  and  the  inflammatory  action  intense, 
in  addition  to  the  above  named  measures  counter-irritation  will  often 
be  very  useful;  mustard,  or  very  stimulating  liniment,  may  be 
applied  along  the  whole  course  of  the  spinal  column,  and  to  the  legs 
and  inside  of  the  thighs.  Some  practitioners  recommend  the  applica- 
tion of  cups  over  the  lumbo-sacral  region,  and  even  leeches  over  the 
abdomen;  there  may  be  cases  in  which  some  transient  benefit  will  be 
derived  from  these,  but  I  have  never  yet  had  occasion  to  employ 
them — still,  I  should  not  hesitate  to  do  so,  were  it  necessary.  But 
general  venesection,  which  was  at  one  time  so  almost  universally 
advised  by  writers,  who  placed  their  greatest  reliance  upon  it,  I  am 
decidedly  opposed  to,  and  am  induced,  from  the  results  of  observation, 
to  believe  that,  at  least  as  frequently  as  the  disease  itself,  it  occasions 
fatal  results. 

Excessive  nervousness  or  sleeplessness  may  be  overcome  by  Sp.  Tr. 
of '  Pulsatilla,  Gelsemium,  or  by  Hydrate  of  Chloral,  Bromide  of 
Potassium,  etc. 


TREATMENT  OF  PUERPERAL  FEVER.  675 

After  the  more  severe  symptoms  have  been  subdued,  many  practi- 
tioners discontinue  the  exhibition  of  the  former  internal  measures, 
substituting  for  them  the  compound  powder  of  Ipecacuanha  and 
Opium,  to  be  given  in  appropriate  doses,  and  at  intervals  of  two  or 
three  hours.  The  internal  administration  of  Sulphate  of  Quinia  will 
be  useful  in  some  cases,  and  under  certain  circumstances,  periodicity 
being  its  principal  indication;  it  maybe  used  in  two  to  five-grain 
doses,  alternating  with  the  compound  powder  just  named,  every  two 
or  three  hours,  and  will  be  found  very  beneficial  in  favoring  a  rapid 
convalescence,  as  it  checks  the  tendency  to  pus-formation,  and  in- 
creases nerve  force.  Any  unpleasant  symptoms  occasioned  by  this 
agent  may  be  removed  by  adding  Bromide  of  Potassium  to  it,  and 
which  addition  will  likewise  enable  us  to  give  the  Quinia  salt  in 
much  larger  doses  without  the  subsequent  development  of  any  dis- 
agreeable results.  Others  prefer  the  compound  powder  of  Quinia. 
These  preparations  may  likewise  be  used  with  advantage  whery 
typhoid  symptoms  are  present. 

Prof.  King  suggests  that  he  has  found  the  tincture  of  Gelsernium, 
either  alone  or  in  combination  with  the  tincture  of  Aconite,  sufficient 
to  resolve  the  disease,  in  some  cases,  without  the  aid  of  other  rem- 
edies; "though,  when  the  attack  is  very  severe,"  he  remarks,  "I 
have  always  found  it  more  advantageous  to  cause  free  diaphoresis." 
Many  others  have  found  similar  benefits  from  the  continued  use,  as 
required,  of  Veratrum  or  Aconite  with  Macrotys. 

It  is  highly  important,  in  all  the  varieties  of  the  disease  under  con- 
sideration, that  all  clots  and  remains  of  the  lochia  and  other  matters 
that  may,  from  decomposition,  form  septic  virus  to  be  absorbed  by 
exposed  surfaces  in  the  uterus  or  vaginal  cavity,  be  carefully  removed 
by  injections  or  by  swabbing  out  the  utero-vaginal  canal  from  time 
to  time  with  some  disinfecting  fluid.  This  is  one  of  the  most  essential 
features  in  the  treatment,  and  for  this  purpose  hot  water  should  be 
used,  to  a  pint  of  which  about  one  drachm  of  Carbolic  Acid  has  been 
added;  I  prefer,  however,  Borax  or  Chlorate  of  Potassium,  or,  in 
some  cases,  Asepsin,  to  Carbolic  Acid;  or  a  weak  solution  of  Per- 
manganate of  Potash  may  be  used,  or  any  of  the  alkaline  sulphites  or 
sulpho-carbolites.  An  infusion  of  Golden  Seal  and  Wild  Indigo  bark 
of  root  has  also  been  advantageously  employed.  These  injections  or 
swabbings  should  be  repeated  several  times  a  day,  being  careful,  when 
the  uterine  cavity  is  injected,  not  to  pass  the  fluid  too  forcibly  into  it, 
nor  in  too  large  a  quantity  at  a  time ;  say  from  two  to  four  fluid 


676  KING'S  ECLECTIC  OBSTETRICS. 

drachms  at  a  time,  and  repeated  at  intervals  of  four  or  five  hours. 
Sometimes  benefit  will  follow  injections  of  warm  water  into  the 
uterus;  from  half  a  pint  to  a  pint  may  be  used  at  a  time,  and  may  be 
repeated  every  three,  four  or  five  hours.  These  swabbintis  and  injec- 
tions should  always  be  given  by  the  medical  attendant — never  by 
the  nurse,  unless  she  be  trained,  and  understands  the  importance  of 
cleanliness  in  such  cases;  they  cleanse  the  organ  from  all  abnor- 
mal and  putrefied  matters,  lessen  the  sufferings  of  the  .patient,  and  aid 
materially  in  restoring  the  parts  to  a  healthy  condition.  Cleanliness 
of  the  bed  and  of  the  utero-vaginal  canal,  pure  or  disinfected  air,  and 
proper  ventilation  of  the  lying-in  room,  are  highly  valuable  hygienic 
auxiliaries  in  the  treatment  of  this  terrible  malady. 

In  addition  to  the  external  application  of  Oil  of  Turpentine  for  the 
tympanitic  condition  of  the  abdomen,  it  will  frequently  become  neces- 
sary to  administer  internal  means;  a  mixture  of  equal  parts  of  Castor 
Oil  and  Oil  of  Turpentine,  may  be  given  in  fluidounce  doses,  and 
repeated  every  two  or  three  hours,  until  gentle  catharsis  is  induced. 
And  when  this  is  employed,  other  cathartics  must  be  omitted.  Though 
it  must  be  recollected  that  cathartics  are  not  always  desirable  when 
tympanitis  is  present,  especially  when  they  tend  to  depress,  or  when 
there  is  a  disposition  to  diarrhea.  Sometimes,  Paregoric  elixir  may  be 
advantageously  added  to  the  dose.  Or,  a  combination  of  equal  parts 
of  Oil  of  Turpentine  and  Paregoric  elixir,  may  be  given  in  small  and 
repeated  doses,  while  other  cathartics  are  being  employed  instead  of 
Castor  Oil.  I  have  met*  with  decided  benefit  from  the  use  of  a 
saturated  tincture  of  Prickly-ash  berries,  as  an  injection  into  the 
rectum,  and  also  administered  internally.  As  an  injection,  it  may  be 
employed  in  half  fluidounce,  or  fluidounce  doses,  very  slightly  diluted 
with  water,  and  repeated  every  half-hour  or  hour.  When  there  is 
much  pain,  half  a  fluidrachm  of  Laudanum  may  be  added  to  each 
injection.  In  some  instances,  I  have  beneficially  combined  it  with 
Oil  of  Turpentine,  with  the  compound  tincture  of  Lobelia  and 
Capsicum,  and  with  these  last-named  two  preparations  together.  In- 
ternally, it  may  be  given  alone  in  fluidrachm  doses,  or,  combined  with 
Oil  of  Turpentine  and  Paregoric  elixir,  equal  parts  of  each,  of  which 
from  half  a  fluidrachm  to  a  fluidrachm,  in  some  sweetened  water,  may 
be  repeated  every  hour  or  two.  The  tincture  of  Prickly-ash  bark 
will  not  exert  the  same  influence  upon  tympanitis,  as  that  of  the 
berries,  which  appears  to  have  almost  a  specific  influence,  and  may  be 
used  per  rectum  at  any  period  of  the  disease  when  tympanitis  is 
present.  Its  use  internally,  or  by  mouth,  must  not  be  commenced 
until  the  higher  inflammatory  action  has  become  somewhat  lessened. 


TREATMENT  OF  PUERPERAL  FEVER.  677 

Vomiting  is  frequently  very  obstinate,  resisting  all  measures  for  a 
length  of  time.  Aconite  and  Ipecac  in  small  doses,  frequently 
repeated,  will  usually  give  desirable  results.  Gelsemium,  alone  or 
combined  with  some  opiate,  does  well  in  some  cases;  or  some  aromatics 
may  be  used,  as  Peppermint-water,  Anise-water,  Spear  mint- water, 
etc.  Minute  doses  of  Morphia  and  Bismuth  may  be  used  \vhere 
other  means  fail.  Frequently  a  Mustard  poultice  to  the  epigastric 
region  will  be  of  service  in  lessening  the  vomiting.  Sometimes 
effervescent  acidulous  draughts  will  be  useful,  as  Soda  or  Seidlitz- 
water,  with  Lemon-juice  and  a  few  drops  of  Laudanum.  And  when 
these  do  not  cause  it  to  yield,  it  will  diminish  with  the  abatement  of 
the  inflammation. 

In  the  TYPHOID  or  MALIGNANT  FORM  of  puerperal  fever, 
the  course  of  management  for  the  first  day  or  two,  during  the  more 
active  stage  of  the  disease,  may  be  the  same  as  in  the  preceding  form, 
but  afterward  it  will  require  considerable  change;  and  the  means 
which  I  am  about  to  advise  for  the  purpose  of  combating  the  typhoid 
symptoms,  may  also  be  employed  when  symptoms  of  a  similar  char- 
acter are  present  in  the  depressing  stage  following  the  inflammatory. 

As  soon  as  it  becomes  evident  that  th.e  disease  is  assuming  the 
typhoid  form,  antiseptics  should  be  administered,  choosing  from  that 
class  of  remedies  such  agents  as  are  specifically  indicated  by  the  symp- 
toms present  in  each  case.  Among  the  different  remedies  to  be  con- 
sidered are  Sulphite  of  Soda,  Chlorate  of  Potassium,  Muriatic  Acid, 
Baptisia,  Sulphurous  Acid.  The  surface  should  be  occasionally 
bathed  with  an  alkaline  bath,  rendered  somewhat  stimulating  by  the 
addition  of  spirits  or  alcohol. 

The  poisonous  condition  of  the  blood,  in  this  disease,  will  be 
frequently  manifested  by  the  pallid,  dirty  tongue,  often  pasty  and 
sticky,  a  disagreeable  taste,  and  frequently  loss  of  appetite ;  such  are 
the  indications  for  Sulphite  of  Soda,  a  remedy  very  often  indicated 
when  the  typhoid  symptoms  appear,  and  if  given  early  will  often 
modify  the  severity  of  the  attack. 

The  indication  for  Chlorate  of  Potash  is  manifested  by  the  putre- 
factive odor  present  with  the  suppression  of  the  lochial  discharge,  the 
unpleasant  odor  of  decomposition,  together  with  bad  smelling  breath. 
Chlofate  of  Potash  511,  Water  giv,  in  teaspoonful  doses  every  two  or 
three  hours. 

Muriatic  Acid  is  called  for  where  the  tongue  shows  the  brown  coat- 
ing, peculiar  to  the  typhoid  state. 


678  KING'S  ECLECTIC  OBSTETRICS. 

Sulphurous  Acid  is  the  agent  when  the  dirty  coat  of  the  tongue 
shows  sepsis.  It  is  a  very  mild  acid. 

The  indication  for  .Baptisia  is  given  by  Prof.  Scudder  as  follows: 
"  It  is  not  so  easy  to  see  the  exact  indications  for  Baptisia,  yet  it  is  one  of 
our  very  best  remedies,  if  the  diagnosis  is  rightly  made.  There  is  a  dull 
red  coloration  of  skin  where  it  has  a  free  circulation,  of  the  lips,  and 
of  the  tongue  and  fauces ;  or,  as  we  sometimes  say,  there  is  an  o/f-color 
of  the  tongue — livid,  purplish,  dull  red.  In  the  advanced  stage  of 
the  disease  (puerperal  fever),  the  tongue  is  protruded  with  difficulty, 
is  stiff,  fissured,  and  bleeds,  and  the  tissues  of  the  mouth  and  fauces 
look  full  and  lifeless.  The  pulse  is  oppressed,  and  the  skin  is  dry, 
husky  apd  lifeless.  The  excretions  are  frequently  fetid.  I  prescribe : 
R.  Tinct.  Baptisia  gtts.;  Water  giv;  a  teaspoonful  every  two  hours, 
usually  alternated  with  the  proper  sedative." 

The  pain  and  tympanitic  condition  of  the  abdomen  must  be  treated 
as  already  described. 

As  soon  as  the  patient  desires  acidulous  draughts,  permit  them  to 
be  taken,  not  forgetting  that  when  the  tongue  is  furred  dark-brown, 
or  yellow,  good  tart  Cider  is  not  only  refreshing,  but  is  powerfully 

sanative  in  its  effects. 

* 
When  the  prostration  is  excessive,  Sherry,  or  sparkling  Catawba 

wine,  porter,  good  French  brandy,  etc.,  must  be  freely  given  to  sup- 
port the  system  until  reaction  comes  on;  together  with  a  light, 
nutritious,  easily  digestible  diet,  as,  solution  of  gelatin,  of  gum  arabic, 
etc.  The  vital  powers  must  be  sustained  by  every  means  possible. 

An  equilibrium  of  the  temperature  of  the  surface  must  be  main- 
Jbained  by  cooling  lotions  to  the  head,  and  warmth'  and  stimulants  to 
the  extremities.  In  some  cases,  where  the  prostration  was  -excessive, 
I  have  applied  cold  to  the  head,  with  sinapisms  around  the  legs  from 
the  hips  down  to  the  feet,  and  around  these  placed  heated  rocks,  or 
bottles  of  heated  water,  and  with  marked  advantage.  It  may  fre- 
quently become  necessary  to  cut  the  hair  close,  when  there  is  much 
disturbance  of  the  brain,  before  applying  the  cooling  lotions. 

When  diarrhea  is  present,  I  know  of  no  better  agent  than  the 
Liquor  Bismuth,  in  half  to  teaspoonful  doses.  Some  physicians  always 
make  use  of  tincture  of  Chloride  of  Iron,  either  with  or  without  some 
preparation  of  Opium.  It  may  be  given  in  doses  of  ten  or  twenty 
drops,  repeated  every  hour,  in  a  sufficient  quantity  of  Avater,  ami  at 
the  same  time,  in  severe  cases,  an  injection,  after  each  diarrheal  evacu- 
ation, should  be  given,  composed  of  Tannic  Acid,  ten  grains; 
Glycerine  and  Water,  of  each  one  fluid  ounce;  mix.  This  should 


TREATMENT  OF  TYPHOID  PUERPERAL  FEVER.        679 

be  retained  by  the  patient  as  long  as  possible.  The  tincture  of 
Chloride  of  Iron  has  a  powerful  and  beneficial  influence  on  the 
capillary  vessels,  and  it  will  not  only  be  found  valuable  in  the 
diarrhea  attending  this  malady,  but  also  in  those  cases  complicated 
with  erysipelatous  indications.  Tannate  of  Quinia  has  also  been 
highly  recommended  when  diarrhea  exists.  Whenever  I  have  good 
reasons  for  knowing  that  an  erysipelatous  condition  is  connected  with 
the  puerperal  fever,  as  soon  as  the  more  active  symptoms  have  been 
somewhat  diminished,  I  administer  fifteen  or  twenty  drops  of  the 
tincture  of  Chloride  of  Iron  in  a  proper  amount  of  water,  repeating 
it  every  hour,  until  the  symptoms  have  yielded,  and  in  no  instance 
has  its  exhibition  been  otherwise  than  beneficial.  In  many  instances 
I  have,  from  the  commencement  of  the  attack,  administered  the 
tincture  of  Veratrum,  and  the  tincture  of  Chloride  of  Iron,  alternately, 
*every  half  hour  or  hour,  and  with  the  most  happy  results.  But 
should  I  meet  with  a  patient  in  whom  it  increased  the  symptoms,  of 
course,  I  should  cease  or  suspend  its  use.  May  not  the  erysipelatous 
and  typhoid  characters  of  this  affection  frequently  be  owing  to  absorp- 
tion of  putrid  matter,  as  decomposition  of  coagula  within  the  uterine 
cavity,  or  of  remaining  pieces  of  placenta  or  membranes? 

In  the  early  stage  of  puerperal  fever  the  diet  must  be  light  and 
cooling,  but  more  nourishing  in  the  latter  stages,  as  gruel,  panada, 
toast,  bread-water,  rice-water,  barley-water,  apple-sauce,  prune-water, 
tamarind- water,  etc.  And  after  the  danger  has  passed,  the  patient 
remaining  much  debilitated,  chicken-broth,  beef-tea,  veal-tea,  etc., 
with  or  without  Sherry  or  other  wine,  brandy,  etc.,  as  the  case  may 
require,  may  be  allowed,  increasing  the  nutritious  character  of  the 
diet  gradually,  as  she  continues  to  improve. 

It  would  be  impossible  to  lay  down  specific  rules  for  the  guidance 
of  the  practitioner  in  treating  the  various  forms  under  which  puer- 
peral fever  may  individually  appear.  The  above  general  principles 
of  treatment  will  be  found  the  most  successful,  although  it  may 
require  to  be  modified,  or  pursued  more  or  less  energetically,  accord- 
ing to  the  phenomena  which  are  present.  Other  means  have  been 
advised,  some  of  which  are  undoubtedly  valuable,  yet  I  have  con- 
sidered it  the  better  course  to  name  only  those  principles  of  treatment, 
in  this  malady,  which  I  have  found  successful  in  my  own  experience. 
And  4n  closing  upon  this  subject,  I  would  remind  the  student  that  not 
only  must  he  carefully  and  attentively  watch  his  patients  who  labor 
under  childbed  fever,  but  he  must  also  use  every  means  to  avoid 
propagating  the  disease,  the  same  as  if  its  contagious  nature  were 
satisfactorily  demonstrated. 


680  KING'S  ECLECTIC  OBSTETRICS. 

Frequently,  the  disease  may  be  prevented  by  an  early  attention  to 
the  bowels  and  kidneys — evacuating  them  by  the  proper  agents; 
keeping  the  utero-vaginal  canal  in  a  cleanly  condition;  maintaining 
a  slight  determination  to  the  surface  by  some  diaphoretic  powder, 
applying  a  fomentation  to  the  abdomen  when  the  pains  are  of  a 
suspicious  character,  and  avoiding  exposures  to  cold,  and  damp  or 
moist  atmosphere.  It  is  sometimes  the  case  that  the  patient  does  not 
promptly  recover  from  the  effects  of  parturition,  but  keeps  her  bed 
for  several  days  more  than  usual,  owing  to  a  sense  of  general  debility ; 
the  milk  is  not  secreted  freely;  the  pulse  is  corded  or  wiry,  somewhat 
bounding,  and  rather  more  frequent  than  natural ;  and  there  is  slight 
pain  or  tenderness  when  deep  pressure  is  made  in  the  hypogastric 
region.  A  slight  elevation  of  temperature  is  likewise  generally 
present.  In  such  instances  there  is  danger  of  an  attack  of  this  affec- 
tion; and  I  have  found  prompt  relief  to  follow  the  administration^, 
every  one,  two,  or  three  hours,  as  the  severity  of  these  symptoms 
would  indicate,  of  a  powder  composed  of  Prussiate  of  Iron,  two  and 
a  half  grains ;  Sulphate  of  Quinia,  two  grains ;  Piperin,  one  grain. 


CHAPTER    XLIX. 

PHLEGMASIA    DOLENS CRURAL    PHLEBITIS TREATMENT    OF 

PHLEGMASIA    DOLENS. 

•»  PHLEGMASIA  DOLENS,  is  the  name  applied  to  a  swelling  of 
one  or  both  legs  which  occurs  soon  after  delivery,  and  is  accompanied 
with  pain  and  tenderness.  The  disease  has  been  termed  milk-leg,  from 
a  mistaken  idea  that  it  was  owing  to  a  metastasis  of  milk  from  the 
breasts  to  the  legs.  It  has  also  received  several  other  names,  accord- 
ing to  the  views  of  writers,  thus,  cedema  dolens,  oedema  lacteum,  phleg- 
masia  alba  dolens  puerper arum,  metastasis  lactis,  depdt  du  lait,  and  crural 
phlebitis.  It  may  attack  primiparae  but  is  more  frequently  met  with 
among  multipart. 

Although  this  disease  has  been  known  to  the  profession  for  a  long 
time,  yet  its  nature  has  not  been  satisfactorily  understood,  and,  even 
at  this  time,  there  are  conflicting  opinions  regarding  it.  Mr.  White, 
of  Manchester,  in  1784,  considered  it  to  be  caused  by  an  obstruction, 
or  some  morbid  condition  of  the  lymphatic  vessels  and  glands  of  the 


PHLEGMASIA    DOLENS*  681 

parts  attacked.  Mr.  Trye,  in  1792,  supposed  it  to  depend  upon  a 
rupture  of  the  lymphatics,  as  they  cross  the  pelvic  brim.  Dr.  Ferrier 
attributed  it  to  inflammation  of  the  absorbents.  Dr.  Hull,  in  1800, 
considered  it  to  be  an  inflammatory  disease,  producing  a  sudden  effusion 
of  serum  and  lymph.  In  1817,  Dr.  Davis  made  an  autopsy,  and  found 
evidences  of  extensive  inflammation  of  the  veins.  In  1823,  M. 
Bouillaud,  supposed  it  to  be  owing  to  obstruction  of  the  crural  vein?, 
having  found  these  veins  obliterated  in  several  females  who  had 
labored  under  the  disease.  In  1829,  Dr.  Robert  Lee  succeeded  in 
tracing  the  inflammation  into  the  uterine  branches  of  the  hypogastrio 
veins,  and  he  gave  it  the  name  of  Crural  Phlebitis. 

A.  commonly  received  opinion,  but  a  few  years  since,  and  which  was 
based  upon  post-mortem  appearances,  was  that  the  immediate  cause  of 
phlegmasia  dolens,  is  inflammation  with  more  or  less  obstruction  of 
the  crural  veins,  the  inflammation,  in  many  instances,  extending  from 
the  uterine  veins,  being  seated  principally  in  the  cellular  and  middle 
tunics  of  the  veins. 

Dr.  Mackenzie,  from  the  results  of  a  scries  of  experiments,  is  of 
the  opinion  that  phlegmasia  dolens  is  owing  to  a  vitiated  condition  of 
the  blood,  and  that  the  venous  inflammation  is  rather  an  effect  of  the 
original  disease.  He  states  that  all  the  phenomena  of  the  affection 
will  not  be  produced  by  inflammation  of  the  iliac  or  femoral  veins 
only ;  that,  during  health,  a  mere  local  cause,  as  inflammation,  or  an 
injury,  does  not  produce  the  extensive  venous  obstruction  which  is 
found  in  phlegmasia  dolens;  that,  independently  of  inflammation  or 
local  injury,  an  obstruction  of  the  veins  may  be  produced  by  an  irri- 
tation of  their  lining  membrane,  and  will  be  more  or  less  extensive 
according  to  the  degree  of  irritation ;  and,  that  we  are  rather  to  look ' 
upon  a  morbid  condition  'of  the  blood  as  the  source  of  this  irritation, 
instead  of  local  injury,  inflammation,  or  disease  of  the  veins. 

These  views  of  Dr.  Mackenzie  appear  to  be  confirmed  by  the  fact, 
that,  phlegmasia  dolens  has  been  kno.wn  to  exist  when  the  uterus  was 
in  a  normal  state,  and  also,  when  the  vessels  of  the  thigh  manifested 
no  indications  of  disease,  this  being  confined  to  the  leg  only;  again, 
females  suffering  under  carcinomatous,  rheumatic,  gouty,  and  other 
diseases,  seem  to  be  more'  liable  to  the  puerperal  swelled  leg  than 
others.  Yet,  it  has  occurred  among  those  who  were  apparently  free 
from  any  disease  up  to  the  time  of  the  attack.  Further  investigations 
will  be  required  before  a  correct  and  satisfactory  theory  of  the  malady 
can  be  determined.  My  own  view  is,  that  the  disease  is  primarily  an 
.affection  of  the  lymphatics,  anfl  that  the  venous  inflammation  is  merely 


682  KINO'S  KCI/KCTIC  OIJSTKTUICS. 

a  secondary  result  of  the  original  malady.  Perhaps,  there  may  exist 
a  previous  vitiated  condition  of  the  blood,  rendering  the  female  more 
readily  susceptible  to  an  attack,  or,  what  is  still  more  probable,  the 
blood  may  be  gradually  poisoned  by  absorption  of  putrid  material, 
and  the  septicemic  action  being  (very  likely  from  embolism)  limited 
or  confined  within  a  certain  sphere,  the  disease  under  consideration 
becomes  developed  instead  of  puerperal  septicemia;  and  some  cases 
have  occurred  under  my  notice  which  would  favor  such  an  idea,  yet, 
at  present,  I  am  not  prepared  to  make  any  positive  statements  rela- 
tive thereto.  A  physician  has  observed  to  me,  in  a  communication  : 
"  From  careful  and  oft-repeated  observations  as  to  the  nature  and  seat 
of  phlegmasia  dolens,  I  have  become  confirmed  in  the  opinion,  that  it 
is  primarily  and  essentially  a  disease  of  the  lymphatic  glands,  and 
subsequently  of  the  lymphatic  vessels  of  the  leg,  the  inflammation  of 
which  extends  to  the  veins,  and  to  the  whole  limb. 

"  This  derangement  of  the  lymphatic  glands,  I  believe  to  be  caused 
by  the  pressure  of  the  head  of  the  fetus  in  passing  through  the  superior 
strait,  and  the  reason  why  the  left  leg  is  more  frequently  the  seat  of 
the  disease  than  the  right,  is  owing  to  the  fact  that  the  occiput  of  the 
child  is  more  generally  directed  to  the  left  side  of  the  pelvis.  At  the 
lower  part  of  the  superior,  and  the  upper  part  of  the  inferior  strait, 
there  are  many  lymphatic  glands  which  are  large  enough  to  be  much 
more  prominent  than  the  nerves  or  veins;  and  they  must  oftentimes 
become  compressed  by  the  occiput  of  the  child  during  its  passage. 
This  pressure  may  cause  the  glands  to  become  inflamed  and  engorged, 
and  the  engorgement  will  cause  an  obliteration  of  the  vessels,  or,  at 
least,  an  obstruction  to  the  free  flow  of  lymph  through  them,  which 
obstruction  will  lead  to  congestion  and  inflammation  of  the  inguinal 
glands,  and  gradually  to  the  lymphatics  of  tlie  entire  lower  extremity. 

"Among  the  phenomena  on  w7hich  I  base  this  opinion,  are,  briefly, 
the  following: 

"1.  The  limb  does  not  become  seriously  implicated  for  some  little 
time  after  confinement. 

"  2.  The  lymphatic  glands  of  the  groin,  and  the  lymphatic  vessels  of 
the  limb  are  involved  for  some  time  before  the  nerves  or  veins  appear 
t'»  be  affected;  as  evidenced  by  the  locality  and  character  of  the  swell- 
ing in  every  case  examined;  and  also  by  the  exudation  of  lymph 
whenever  scarification  has  been  employed. 

"  3.  The  general  lymphatic  engorgement  of  the  whole  limb,  and  the- 
cold,  white  appearance  of  the  part,  centra-indicate  inflammation  of  the- 
veins,  or  of  any  other  tissue  except  the  lymphatics. 


PHLEGMASIA   DOLENS.  683 

U4.  The  invasion  of  exactly  the  same  form  of  disease  in  the  arm  of 
one  man  after  amputation,  where  the  lymphatic  glands  of  the  axilla 
had  become  involved,  and  the  lymphatic  vessels  of  the  whole  arm  had 
become  engorged ;  and,  also,  the  appearance  of  two  other  cases  of 
phlegmasia  in  the  legs  of  men  where  certainly  the  lymphatics  were 
first  involved.  "Writers  have  also  observed  the  same  phenomena 
among  males. 

"  5.  The  veins  can  not,  in  my  opinion,  be  the  primary  seat  of  the 
disease,  for  they  do  not  appear  to  be  affected  until  after  the  disease  has 
existed  some  days,  and,  in  a  few  instances,  even  for  weeks,  after  the 
affection  of  the  lymphatics. 

"  6.  The  veins,  when  inflamed,  do  not  present  the  same  phenomena 
in  any  other  part  of  the  system  as  are  observed  in  phlegmasia  dolens, 
as,  effusion  of  lymph,  a  white,  shining  surface,  and  a  low  grade  of 
temperature. 

"  7.  The  treatment  which  is  found  the  most  successful  in  cutting 
short  the  disease  in  its  earlier  stages,  is  not  such  as  would  be  demanded 
if  the  veins  or  nerves  were  primarily  affected,  but,  is  such  as  would  be 
used  for  inflammation  of  the  lymphatic  glands,  and  vessels  elsewhere." 
Although  I  do  not  wholly  participate  in  these  views,  I  give  them  on 
account  of  the  description  of  the  phenomena  attending  the  disease. 

Phlegmasia  dolens,  although  more  commonly  met  with  among 
puerperal  females,  is  by  no  means  confined  to  them;  it  has  been 
observed  among  those  whose  menstrual  discharge  has  been  suddenly 
suspended ;  or  who  have  had  diseases  of  the  uterine  organs,  as  malig- 
nant ulceration  of  the  cervix,  polypus,  etc.  Nor  do  males  appear  to 
be  exempt  from  it,  for  it  has  been  known  to  occur  in  them,  following 
dysentery,  diarrhea  with  ulcerated  intestines,  cancer  of  the  rectum, 
external  injuries,  amputation  of  a  limb,  etc.  A  similar  affection  has 
likewise  been  observed  to  attack  the  arms  in  both  males  and  females, 
after  some  injury  of  the  upper  part  of  the  body,  or,  during  some 
carcinomatous  disease  of  the  breast.  In  any  one  of  the  above  mentioned 
diseases  or  conditions,  will  be  observed  the  possibility  of  decomposi- 
tion and  formation  of  septic  material  that  may  be  absorbed  into  the 
system. 

Various  exciting  causes  have  been  named,  the  most  common  among 
which  is  cold:  it  is  said  also  to  be  excited  by  pressure  upon  the  pelvic 
veins  and  nerves,  uterine  disease,  suppurative  inflammation  of  the 
pubes,  injuries,  inflammation  of  the  sciatic  and  obturator  nerves,  and 
sometimes  to  occur  as  a  sequel  of  fever. 


684  KING'S  ECLECTIC  OBSTETRICS. 

SYMPTOMS. — This  disease  most  commonly  appears  between  the 
tenth  and  fifteenth  day  after  delivery;  though  it  has  been  met  with 
as  early  as  on  the  fourth  day,  and  again  at  a  later  period,  even  after 
the  third  week.  It  is  generally  preceded  by  pains  or  uneasiness  in 
the  lower  part  of  the  abdomen,  with  symptoms  of  uterine  or  venous 
inflammation,  and  a  feeble,  depressed,  or  irritable  condition  of  the 
patient;  frequently  the  patient  is  suddenly  attacked  without  any  pre- 
monitory symptoms. 

It  usually  manifests  itself  with  severe  rigors,  followed  by  an  in- 
creased temperature  of  the  surface,  and  by  a  sudden  and  deep-seated 
pain  in  the  groin,  or  thigh.  After  a  few  hours  the  affected  limb 
commences  swelling,  and  usually  upon  its  inner  and  anterior  surface. 
In  the  greater  number  of  cases,  this  swelling  is  first  observed  in  the 
calf,  sometimes  extending  to  the  inside  of  the  heel,  from  whence  it 
travels  rapidly  upward;  occasionally,  it  extends  from  the  thigh  down- 
ward. Not  unfrequently,  before  any  pain  in  the  thigh  or  groin  is 
experienced,  the  calf  of  the  leg  will  be  found  swollen,  painful,  and 
hard,  as  if  it  were  attached  to  the  bone,  and  can  not  be  shaken,  while 
the  calf  of  the  other  limb,  on  being  shaken,  will  be  found  flabby  and 
movable.  It  is  not  unusual  for  the  buttock,  and  labium  pudendi  of 
the  diseased  side,  to  share  in  the  abnormal  action. 

The  swelling  is  hard  and  elastic,  the  skin  is  tense,  shining,  white, 
and  exceedingly  sensitive  to  the  touch,  with  an  augmented  temperature, 
and  all-hough  yielding  to  pressure,  does  not  leave  a  pit,  except  upon 
the  parts  which  are  free  from  pain,  or  at  the  decline  of  the  disease. 
In  the  direction  of  the  femoral  vein,  a  hard,  exceedingly  painful  cord 
may  be  felt,  which  is  the  thickened  and  indurated  vein;  sometimes, 
an  enlargement  of  the  inguinal  glands  may  be  detected.  If  the  limb 
be  punctured,  only  a  few  drops  of  a  gelatinous  fluid  will  be  discharged. 
As  the  swelling  progresses,  there  is,  generally,  some  abatement  of 'the 
pain,  but  not  an  entire  removal. 

The  pain  accompanying  the  swelling  is  very  severe,  and  is  much 
aggravated  by  any  motion  of  the  limb,  or  even  by  the  slightest  pres- 
sure. It  is  usually  more  intense  on  the  inside  and  back  of  the  thigh, 
in  the  direction  of  the  internal  cutaneous,  and  crural  nerve.  Sometimes 
it  commences  in  the  back  and-hip-joint.  It  is  constant,  though  there 
may  occasionally  be  slight  remissions ;  and  the  best  position  in  which 
the  limb  can  be  placed  is  to  have  it  slightly  elevated  upon  an  inclined 
plane,  having  an  angle  of  from  6°  to  10°;  or,  it  may  be  flexed  both  at 
the  knee  and  hip-joints.  In  a  depressed  or  depending  position,  the 
pain  will  be  much  augmented.  From  the  commencement  of  the 


TREATMENT    OF    PHLEGMASIA    DOLEXS.  685 

attack,  the  affected  limb  feels  heavy  and  stiff,  and,  as  the  disease  pro- 
gresses, the  patient  will  be  unable  to  move  it,  not  only  from  the 
excessive  pain  produced,  but,  because  the  limb  has  become  powerless. 

In  connection  with  the  pain  and  swelling,  there  will  be  more  or  less 
fever,  headache,  nausea,  or  vomiting,  quick  and  feeble  pulse,  giving 
frequently  130  to  140  beats  in  a  minute;  thirst,  restlessness,  and 
sleeplessness.  The  bowels  are  usually  constipated;  the  urine  turbid, 
and  small  in  quantity;  the  lochia  are  suppressed,  or  fetid,  sometimes 
the  discharge  remains  unaltered;  together  with  other  symptoms, 
varying  in  degree,  but  indicative  of  the  general  disturbance  to  the 
constitution.  These  disappear  gradually  as  the  pain  diminishes,  leaving 
the  patient  extremely  debilitated.  Sometimes,  there  will  be  a  copious 
perspiration  throughout  the  whole  course  of  the  disease,  which  will 
debilitate  the  patient  very  much. 

It  is  very  seldom  that  phlegmasia  dolens  attacks  both  limbs  at  once ; 
though  it  may  happen,  that  when  the  pain  and  swelling  of  the  lirnb 
first  attacked  subsides,  the  disease  will  manifest  itself  in  the  other  one. 
It  usually  lasts  from  four  to  six  or  seven  weeks,  though  the  acute 
stage  may  continue  for  only  ten  or  fifteen  days.  It  may  terminate  in 
resolution,  the  swelling  disappearing,  and  perfect  use  of  the  limb  being 
restored;  or,  the  swelling  may  take  place  slowly,  the  female  not  wholly 
recovering  the  use  of  the  affected  limbs.  Suppuration,  with  ulcerationr 
occasionally  occurs,  the  consequent  exhaustion  eventually  destroying 
the  woman.  And  sometimes,  death  occurs  either  suddenly,  as  for 
instance,  when  the  patient  raises  herself  in  the  bed,  or  it  may  take 
place  gradually  from  the  secondary  affections  induced.  Most  generally, 
the  acute  symptoms  are  followed  by  a  chronic  form,  in  which  the  limb 
never  returns  to  its  original  size,  and  remains  almost  powerless  through 
life. 

DIAGNOSIS. — This  affection  may  be  known,  by  its  occurring 
within  a  few  days  or  weeks  after  delivery;  by  the  pain  down  the 
affected  limb;  by  the  hardness  of  the  swelling;  the  attending  fever; 
and  the  hard,  cord-like,  and  painful  condition  of  the  femoral  vein.  If 
the  calf  of  the  leg  is  firm,  hard,  immovable,  and  painful  on  being 
compressed,  and,  if  pain  is  produced  in  the  upper  part  of  the  limb  on 
rotating  it,  these  are  positive  indications  of  crural  phlebitis.  The 
left  side  is  more  commonly  attacked  with  the  disease  than  the 
right. 

PROGNOSIS. — The  disease  seldom  proves  fatal.  The  less  severe 
the  fever  and  the  swelling,  the  milder  will  be  the  attack.  When  a 
favorable  change  is  about  to  occur,  the  pain  gradually  diminishes, 
leaving  a  numbness  of  the  leg  for  some  time;  the  swelling  softens  and 
becomes  oedematous,  pitting  upon  pressure. 


68G  KING'S  ECLECTIC  OBSTETRICS. 

POST-MORTEM  APPEARANCES.— The  cellular'membrane  of 
the  limb  will  be  found  distended  with  effused  serum.  The  affected 
vein  will  be  obliterated  by  adhering  clots  of  blood,  or  coagulable 
lymph;  its  parietes  thickened;  its  inner  tunic  of  a  deep*  color;  and 
pus  may  be  contained  within  its  canal.  Pus  may  likewise  be  found, 
together  with  evidences  of  inflammatory  action,  in  the  absorbents ; 
small  abscesses  may  be  observed  in  the  substance  of  the  affected  leg; 
and  frequently,  traces  of  secondary  affections  in  the  joints,  cavities, 
etc.,  may  be  present. 

The  veins  most  commonly  attacked,  are  the  femoral,  iliac,  epigastric, 
spermatic,  uterine,  and  vaginal,  the  saphena,  and  the  vena  cava. 

TREATMENT. — During  the  acute  stage,  the  indication  is  to  elim- 
inate or  neutralize  the  absorbed  poison,  and  to  allay  inflammatory 
action ;  and  in  the  second  or  chronic  stage,  to  promote  absorption  of 
effused  fluid  and  restore  the  venous  circulation. 

To  fulfill  the  first  indication,  both  general  and  local  measures  will 
be  required.  Among  the  general  measures,  the  first  which  demand 
our  attention,  provided  there  is  no  diarrhea,  is  the  administration  of  a 
brisk  cathartic,  as,  for  instance,  the  compound  powder  of  Jalap,  with 
some  Nitrate,  or  Bitartrate  of  Potassa  added ;  or,  the  indication  for 
Podophyllin  may  be  present — the  heavily  coated  tongue  at  base — 
when  a  few  doses  of  the  first  or  second  decimal  trituration  may  be 
given.  The  purgative  should  be  administered  in  a  dose  sufficient  to 
act  thoroughly,  without  a  repetition  of  it  writhin  four  or  five  hours. 
It  not  only  empties  the  intestinal  tract,  removing  any  existing  mor- 
bid accumulations,  but  it  likewise  has  a  revulsive  and  eliminative 
effect,  and  renders  the  system  more  susceptible  to  the  beneficial 
influences  of  subsequent  medication.  If  necessary,  the  cathartic  may 
be  repeated  again  on  the  second  or  third  day;  and  during  the  whole 
period  of  the  acute  stage  the  bowels  must  be  kept  free,  causing  one 
evacuation  daily.  In  some  cases  Nux  Vomica  will  answer  a  good 
purpose,  especially  where  we  have  the  sallow,  expressionless  face, 
more  or  less  nausea,  broad  and  flabby  tongue;  symptoms  depending 
on  a  bad  condition  of  the  stomach. 

After  the  catharsis,  agents  must  be  administered  for  the  purpose  of 
aHaying  the  inflammation  and  lessening  the  pain.  The  proper  sed- 
ative should  be  first  selected,  which  will  be  Veratrum  in  most  cases; 
to  this  will  be  added  the  indicated  remedy.  Macrotys  will  usually 
control  the  severe  pain  to  a  considerable  degree.  In  some  cases  the 
remedy  will  be  Gelsemium,  or,  when  the  pain  is  particularly  of  a 
burning  nature,  Rhus  Tox  should  be  thought  of,  and  continued  or 


TREATMENT    OF    PHLEGM  ASIA    DOLENS.  687 

changed  according  to  the  degree  of  inflammatory  action,  and  the 
influence  of  the  remedy.  Sometimes,  and  more  especially  when  the 
pain  is  intense  with  high  inflammation,  the  Sp.  Tr.  of  Aconite 
m;iy  be  added  to  the  above  compound,  according  to  the  influence  it 
exerts  upon  the  system.  The  above  agent  will  most  generally  be  found 
to  act  promptly  in  subduing  the  more  active  symptoms. 

Other  combinations,  of  equal  value^  may  be  used  to  fulfill  the  same 
indication;  thus,  the  tincture  of  Gelsemium,  administered  either  alone 
or  in  conjunction  with  the  tincture  of  Aconite,  will  be  found  to  exert 
a  prompt  and  beneficial  influence.  Sp.  Tr.  of  Iris  has  been  used  by 
many  practitioners,  and  with  excellent  results.  I  have  also  derived 
great  benefit,  in  two  cases,  from  the  internal  administration  of  Phyto- 
lacca,  assisted  by  its  local  application. 

Occasionally,  when  there  is  no  mitigation  of  the  pain  by  -the  above 
means,  the  Sulphate  or  Acetate  of  Morphia  may  be  prescribed  in  doses 
of  one-fourth  or  one-half  a  grain,  and  repeated  as  may  be  required; 
this  may  be  given  more  particularly  when  the  patient  is  restless, 
irritable  and  sleepless.  Chloral  hydrate  has  likewise  been  highly 
recommended;  also,  subcutaneous  injections  of  Sulphate  of  Morphia. 

Salicylic  Acid  lias  been  found  useful  in  some  cases,  especially  when 
there  is  lochial  fetor,  and  severe  pain.  Bryonia,  Belladonna  and 
Apocynum  are  all  valuable  remedies,  and  should  be  administered 
according  to  the  special  indications  calling  for  them.  The  same 
measures  must  be  pursued  as  named  in  the  treatment  of  puerperal 
septicemiay  with  regard  to  cleanliness,  pure  air,  ventilation,  oxygen- 
ation  of  the  blood,  and  antiseptics,  as  well  as  to  nervousness,  sleep- 
lessness, etc. 

Gastralgia.,  or  a  burning  pain  in  the  epigastric  regiop,  is  sometimes 
present,  and  may  be  relieved  by  the  administration  of  a  powder  com- 
posed of  Nitrate  of  Bismuth,  ten  grains;  Lupulin,  two  or  four  grains; 
and  this  may  be  repeated  every  four  or  five  hours.  An  infusion  of 
Peach-leaves  will  also  relieve  it,  as  well  as  the  tinctures  of  Gelsemium 
and  Aconite,  or,  when  these  fail,  Nux  Vomica. 

Among  the  local  measures,  fomentations  to  the  affected  limb  occupy  a 
prominent  position.  Vinegar  in  which  Hops  have  been  boiled,  or  an 
infusion  of  Water  Pepper  (Polygonum  punctatuni)  may  be  applied  to 
the  whole  limb  by  means  of  flannel  cloths.  Sometimes  a  warm 
application  will  be  found  the  most  advantageous,  at  others  a  cold  one ; 
this  point  must  be  determined,  by  the  practitioner,  according  to  the 
peculiarities  of  each  individual  case.  Generally,  cold  applications 


688  KING'S  ECLECTIC  OBSTETRICS. 

will  be  preferable,  but  when  they  occasion  a  sense  of  cold  or  chilliness,, 
they  are  contra-indicated,  and  the  warm  applications  must  be  sub- 
stituted. Sometimes  a  bandage  may  be  loosely  applied  along  the 
whole  limb  from  the  toes  to  the  groins,  which  should  be  kept  con- 
stantly moistened  with  cold  or  warm  water,  or  with  a  mixture  of  water 
and  spirits;  and  frequently,  a  solution  of  Hydrochlorate  of  Ammonia 
will  be  found  most  valuable;  be  careful  not  to  bandage  tightly  in  the 
acute  stage. 

The  affected  limb  must  be  handled  most  carefully,  and  be  protected 
from  pressure  of  the  bed  clothes,  etc.,  -\\  heu  these  occasion  or  increase 
the  pain.  A  very  excellent  local  application,  when  the  skin  is 
unbroken,  is  a  mixture  of  saturated  solution  of  Hydrochlorate  of 
Ammonia,  tincture  of  Arnica,  tincture  of  Camphor,  and  Chloroform, 
equal  parts  of  each ;  this  should  be  frequently  painted  over  the  pain- 
ful parts.  Sometimes  the  pain  and  swelling  »have  been  greatly 
alleviated  by  hot  Turpentine,  applied  to  the  whole  limb  by  means  of 
light  cloths,  repeating  the  application  several  times  a  day,  twenty  or 
thirty  minutes  each  time.  A  solution  of  extract  of  Belladonna,  fre- 
quently painted  upon  the  limb  along  the  painful  part,  has  also  been 
found  of  efficacy. 

In  the  early  part  of  the  attack,  much  advantage  may  be  derived 
from  the  application  of  cups  or  leeches  on  the  limb,  along  the  course 
of  the  pain,  and  many  of  our  practitioners  have  beneficially  employed 
these.  I  have  always,  heretofore,  succeeded  without  them,  but  should 
not  hesitate  a  moment  to  use  them  in  any  case  where  I  considered  it 
necessary. 

But,  of  all  the  applications  to  the  limb  during  the  intensity  of  the 
attack,  I  kno*v  of  none  superior  or  equal  to.recent  Stramonium  leaves 
when  these  can  be  obtained.  They  should  be  bruised,  and  the  whole 
limb  covered  with  them.  It  is  considerable  trouble  to  collect  and 
prepare  the  remedy  in  this  manner,  but  a  similar  benefit,  though  in  a 
minor  degree,  may  be  obtained  by  bruising  the  leaves,  and  placing 
them  in  hot,  not  boiling,  water,  and  applying  this  infusion,  either 
warm  or  cold,  by  means  of  flannel  cloths!  The  application  may  also 
be  extended  across  the  hypogastric  region  with  advantage.  Dried 
Stramonium  leaves  do  not  exert  the  same  prompt  and  decided  in- 
fluence over  the  inflammation,  but  their  action  may  be  improved  by 
combining  them  with  an  equal  quantity  of  Lobelia,  and  applying  as 
above.  The  extract  of  Stramonium,  or,  of  Belladonna,  rendered  thin, 
and  applied  on  lint  along  the  course  of  the  pain,  will  frequently  be 
of  service. 


TREATMENT  OF  PHLEGMASIA  DOLEXS.  689 

Blisters  applied  more  especially  to  the  groin  of  the  affected  limb,  or 
along  the  course  of  the  pain,  have  been  used  with  favorable  results 
by  many  practitioners,  though  I  have  never  found  it  necessary  to 
employ  them  in  my  own  practice.  I  have,  however,  frequently  and 
beneficially  applied  a  sinapism  across  the  sacral  and  lumbo-sacral 
regions,  and  I  prefer  this  to  a  blister  on  these  points,  on  account  of 
the  decubitis  being  principally  and  for  some  time  upon  the  back,  or 
nearly  so. 

It  should  be  stated  that  Sulphate  of  Iron,  locally  applied,  aided  by 
the  internal  administration  of  large  doses  of  tincture  of  Chloride  of 
Iron,  has  effected  cures  where  other  means  had  failed.  From  eighty 
to  one  hundred  and  twenty  grains  of  the  Iron  Sulphate  is  dissolved  in 
four  fluidounces  of  water,  and  this  solution  must  be  applied  on  cotton, 
lint,  or  spongio-piline,  to  the  affected  limb,  as  hot  as  can  be  comfort- 
ably borne  by  the  patient,  repeating  it  frequently.  These  remedies, 
beside  having  an  antiseptic  property,  possess  likewise  the  power  of 
controlling  vascular  dilatation. 

The  patient  should  be  kept  as  quiet  as  possible  during  the  inflam- 
matory stage,  the  apartment  should  be  kept  at  a  moderate  temperature, 
and  she  must  be  restricted  to  a  low  and  cooling  diet.  After  the 
removal  of  this  stage,  a  more  nourishing  diet  may  be  allowed,  and 
should  there  be  much  debility,  tonics,  or  wine  may  be  judiciously 
administered. 

After  the  inflammatory  symptoms  have  been  subdued,  measures 
must  be  taken  to  promote  absorption  and  restore  venous  circulation. 
Internally,  Sp.  Tr.  Harnamelis  and  Collinsonia  may  be  given,  3!  to  ii 
lo  5iv  of  Water,  and  continued  in  teaspoonful  doses  for  some  time.  In 
the  advanced  chronic  stage  alteratives  must  also  be  used,  as,  some 
preparation  of  Iodine,  the  compound  syrup  of  Stillingia  and  Iodide  off 
Potassium,  or  the  compound  syrup  of  Yellow  Dock  may  be  substi- 
tuted. Hydrochlorate  of  Ammonia  may  be  beneficially  ehiployed  at 
this  period  of  the  disease ;  five  or  ten  grains  in  solution,  or  syrup, 
may  be  administered  every  two  or  three  hours;  or  it  may  be  added 
to  the  above  syrups  instead  of  the  Iodide  of  Potassium.  The  Sp. 
Tr.  of  Iris,  in  five-drop  doses,  answers  a  very  good  purpose  also. 

The  limb  should  be  carefully  bandaged  from  the  toes  t'o' the  thigh, 
but  not  so  tightly  as  to  render  the  patient  uncomfortable.  As  the 
bandage  will  require  to  be  removed  and  reapplied  twice  in  the  course 
of  every  twenty-four  hours,  these  periods  may  be  improved  for  the 
purpose  of  applying  friction,  as  well  as  some  stimulating  liniment  or 
44 


690  KING'S  ECLECTIC  OBSTETRICS. 

wash,  to  the  limb ;  and  the  bandage  may  even  be  kept  moist  with  the 
same  stimulant,  or  with  a  solution  of  Hydrochlorate  of  Ammonia, 
liniment  of  Iodine,  etc.  Currents  of  galvanism  or  electro-magnetism 
may  likewise  be  passed  through  the  limb  once  or  twice  daily,  more 
especially  in  the  advanced  chronic  stage.  Of  course,  as  in  the  acute 
stage,  the  limb  should  be  kept  in  an  elevated  position,  for  such  a 
length  of  time  as  may  be  deemed  proper,  in  order  to  render  the  cure 
thorough  and  permanent.  An  irritating  plaster  over  the  sacrum,  or, 
over  the  lumbo-sacral  region,  ought  never  to  be  omitted  in  the  second 
stage — it  tends  greatly  to  facilitate  the  cure.  The  sore  produced  by 
it  should  be  kept  discharging  as  long  as  the  patient  can  bear  it.  And 
after  it  has  healed,  if  its  further  employment  be  indicated,  do  nof 
hesitate  to  apply  it.  I  know  it  is  exceedingly  painful  and  annoying, 
but  its  advantages,  in  this  disease,  repay  its  disadvantages  a  hundred 
times  over. 

Whenever  the  lochial  discharge  is  fetid,  whether  in  the  first  or 
.second  stage  of  the  dis'ease,  hot  water,  in  which  has  been  dissolved 
Borax  or  Chlorate  of  Potash,  in  the  proper  proportion;  diluted 
Pyroligneous  Acid;  Carbolic  Acid,  one  part  to  one  hundred  of  Water; 
or  some  other  disinfecting  liquid,  may  be  injected  into  the  vagina, 
two  or  three  times  a  day.  Cleanliness,  etc.,  have  already  been 
referred  to. 

Any  abscesses,  or  ulcers  of  the  leg,  caused  by  the  disease,  which  may 
present  themselves,  are  to  be  treated  upon  the  same  principles  as  other 
ulcers. 

In  this  stage,  the  patient  should  be  allowed  to  sit  up  more  or  less 
during  the  day,  but  never  with  the  limb  in  a  depending  position; 
the  diet  should  be  nourishing  and  of  easy  digestion,  and  tonics,  wine 
in  moderate  quantity,  or  wine  and  Peruvian  bark,  and  even  good 
brandy,  must  be  allowed  when  there  is  much  debility.  In  the  more 
advanced  stages  of  the  disease,  sea-bathing  has  been  recommended, 
and  may,  probably,  be  occasionally  useful. 

The  above  treatment  will,  in  the  majority  of  instances,  effect  a  per- 
fect cure,  if  it  be  commenced  sufficiently  early,  but  the  practitioner 
must  not  be  disappointed  in  occasionally  finding  patients  who,  notwith- 
standing the  active  and  energetic  means  employed,  recover  only  to  carry 
for  the  remainder  of  their  existence,  a  debilitated  and  enlarged  limb. 


PUERPERAL    MANIA.  691 


CHAPTER    L. 

PHRENITIS PUERPERAL      MANIA TREATMENT      OF      PUERPERAL 

MANIA INTESTINAL   IRRITATION ACUTE 

TYMPANITIS — DIARRHEA. 

INFLAMMATION  of  the  brain  and  its  membranes  is  sometimes  met 
with  in  puerperal  females;  there  will  be  headache,  flushing  of  the 
face,  throbbing  of  the  arteries,  intolerance  of  light  and  sound,  delir- 
ium, and  all  the  symptoms  of  an  ordinary  phrenitis.  The  treatment 
will  not  vary  from  that  usually  pursued  when  the  inflammation 
occurs  at  other  periods. 

It  may  be  proper  to  observe  here  that,  for  five  or  six  weeks  after 
delivery,  females  are  subject  to  severe  cerebral  derangement,  from  eat- 
ing indigestible  articles  of  diet,  or  from  partaking  too  freely  at  rneals. 
The  most  common  symptoms  in  such  cases  are,  headache,  delirium, 
Insensibility,  convulsions,  and  death.  They  must  be  actively  treated 
by  the  usual  means  for  such  disturbance,  but  it  will  frequently  be 
found  that  treatment  produces  no  amelioration  of  the  symptoms,  the 
disease  steadily  advancing  toward  a  fatal  termination. 

PUERPERAL  MANIA,  is  more  frequently  met  with  than  puer- 
peral phrenitis,  and  is  said  to  occur  more  frequently  among  unmarried 
females  than  others.  Those  of  an  excitable  or  very  sensitive  disposi- 
tion are  the  most  liable  to  it,  though  no  constitution  or  temperament 
is  exempt.  It  may  occur  during  gestation,  during  parturition,  or 
subsequently ;  the  most  usual  periods  of  attack  are  a  few  hours  or 
days  after  labor,  before  the  system  has  fully  recovered  from  the  shock ; 
and,  at  some  period  previous  to  weaning,  when  the  constitution  is 
suffering  from  the  debilitating  influence  of  lactation.  It  may  con- 
tinue for  a  few  days,  or  months,  and  frequently  many  years  may 
intervene  between  the  commencement  of  the  attack  and  the  mental 
restoration ;  occasionally  the  mania  continues  through  life. 

There  is  a  species  of  delirium  which  is  occasionally  observed  when 
the  head  of  the  child  is  passing  through  the  os  uteri,  or  when  it  is 
distending  the  perineum,  and  which  is  probably  caused  by  the  excessive 
pain  experienced  at  these  times.  It  is  not  permanent  in  its  character, 
generally  disappearing  shortly  after  the  passage  of  the  child  through 


692  KINO'S  ECLECTIC  OHSTKTKK >. 

the  parts.  The  female  is  frequently  aware  of  the  wild  ness  and  absurd- 
ities of  her  thoughts  and  expressions  during  this  period,  but  this  is 
not  puerperal  mania. 

Puerperal  insanity  is  frequently  hereditary,  all  the  females  of  a 
family,  from  generation  to  generation,  being  subject  to  more  or  less 
mental  derangement  at  the  parturient  period ;  and  when  this  is  known 
to  be  the  case  with  a  pregnant  female,  the  practitioner  should  endeavor 
to  ward  off  an  attack  by  proper  treatment  during  the  gestating  months, 
I  am  not  aware  whether  the  use  of  Chloral  Hydrate  during  the  period 
of  labor,  or  the  production  of  anaesthesia  by  Chloroform,  has,  in  these 
cases,  prevented  the  maniacal  attack,  but,  as  it  appears  to  me,  they 
certainly  deserve  a  trial.  A  common  predisposing  cause  is  the  extreme 
susceptibility  or  excitability  of  the  nervous  system  and  brain  to  which 
pregnant  females,  as  well  as  those  who  give  suck,  are  subject,  and 
which  renders  them  exceedingly  liable  to  morbid  impressions. 

Mental  emotions,  as  a  great  anxiety  relative  to  her  condition,  or  a 
state  of  depression,  or  a  severe  fright  occurring  during  pregnancy, 
may  likewise  predispose  the  female  to  an  .attack  of  mania  ;  and  a  very 
common  predisposing  cause  is  stated  to  be  derangement  of  the  digestive 
functions.  Profuse  hemorrhage  has  also  been  considered  a  predisposing 
cause. 

The  exciting  causes  are  many ;  as  irritation  of  the  breasts,  uterine 
irritation,  suppression  of  lochia,  the  vascular  disturbance  caused  by 
labor,  suckling,  nervous  shock  of  labor,  cold,  and  frequently  it  occurs 
without  any  assignable  cause. 

SYMPTOMS. — These  do  not  vary  essentially  from  those  which 
occur  during  the  insanity  of  non-pregnant  females,  or  of  males.  The 
attack  may  come  on  suddenly,  or  it  may  take  place  gradually,  and  is 
frequently  preceded  by  more  or  less  headache,  nervous  irritability,  and 
sometimes  derangements  of  the  digestive  organs.  In  one  form  of  the 
malady,  the  female  will  be  restless  and  sleepless,  incessantly  talking, 
and  expressing  herself  in  a  wild,  disconnected,  and  most  absurd  man- 
ner ;  in  another  form,  she  will  be  depressed  and  melancholy.  Females 
have  been  known  to  escape  the  watchfulness  of  their  attendants  when 
attacked  by  puerperal  mania,  and  roam  for  a  great  distance  from  home, 
even  through  snow  and  severe  cold  weather,  and  without  any  other 
result  than  a  restoration  to  sanity ;  which,  however,  would  probably 
have  occurred  independent  of  such  exposure  and  exercise. 

It  would  occupy  more  space  than  is  necessary  in  the  present  work, 
to  detail  the  various  symptoms  which  may  occur  in  this  disease ;  suffice 
it  to  say,  that  though 'there  may  be  some  peculiarities  attending  it,  yet 


PUERPERAL    MANIA.  693 

the  general  symptoms  present  the  same  features  as  those  of  the  several 
varieties  of  insanity  met  with  at  other  times. 

There  are  two  opposite  conditions  of  the  vascular  system  in  this 
disease  ;  one  is  accompanied"  with  more  or  less  fever,  a  quick  pulse 
ranging  from  120  to  140  beats  in  a  minute,  headache,  throbbing  of  the 
carotids,  flushed  face,  intolerance  of  light,  great  mental  excitement 
with  incessant  raving,  it  being  almost  impossible  to  restrain  the 
patient.  The  tongue  is  usually  coated  with  a  slimy  fur;  the  urine  is 
turbid  and  scanty;  the  secretion  of  milk  diminished,  as  well  as  its 
nutritive  qualities ;  the  bowels  constipated;  the  lochia  suppressed,  or 
natural;  and  often  a  peculiar  and  offensive  odor  emanates  from  the 
various  excretions.  If  a  disposition  to  commit  violence  is  present,  it 
is  commonjy  directed  against  others,  and  not  against  herself. 

In  the  other  condition,  the  pulse  is  feeble  and  but  slightly  acceler- 
ated ;  the  temperature  of  the  surface  is  natural  or  diminished  ;  there 
is  but  little  or  no  headache ;  the  tongue  is  coated  white  ;  the  bowels 
are  constipated ;  the  countenance  is  pale  and  sunken,  but  sometimes 
calm  and  tranquil,  with  a  gradually  progressing  emaciation.  In  this 
condition  the  patient  is  usually  in  a  depressed  or  melancholy  state,  and 
is  frequently  aware  of  her  situation ;  there  is  more  or  less  mental 
apprehension,  perhaps  a  religious  mania,  with  great  physical  inactivity, 
and  a  strong  tendency  to  commit  suicide. 

Puerperal  mania  may  terminate  in  a  few  hours,  the  mind  being 
perfectly  restored ;  or  it  may  continue  for  months  or  years,  with 
ultimate  recovery ;  or  it  may,  as  has  been  observed  in  a  few  cases,  be 
permanent  and  incurable ;  or  it  may  terminate  in  death,  especially 
in  the  raving  variety,  which  is  attended  with  quick  pulse  and  febrile 
symptoms. 

DIAGNOSIS. — Puerperal  mania  may  be  confounded  with  phrenitis; 
but  although  the  pulse  be  quick  in  mania,  it  is  not  so  sharp  and  hard 
as  in  cerebral  inflammations,  nor  is  there  such  a  high  degree  of  the 
heat  of  the  surface  and  of  the  febrile  symptoms ;  in  phrenitis  there  is 
an  intolerance  of  light  and  sound,  which  is  seldom  the  case  in  mania : 
phrenitis  is  attended  with  fever,  headache,  and  other  inflammatory 
symptoms,  for  some  time  before  delirium  manifests  itself,  while  in 
mania  the  incoherency  exists  from  the  commencement. 

It  may  be  determined  from  congestive  headache,  by  observing  that 
this  does  not  commence  with  delirium :  and  from  delirium  tremens,  by 
learning  the  history  of  the  case,  the  previous  habits  of  the  patient,  and 
by  attending  to  the  attack,  which,  in  delirium  tremens,  is  not  sudden, 
and  is  attended  with  a  cold,  clammy  skin,  profuse  sweats,  tremors,  and 
tremulousness  of  the  tongue. 


694  KIM.'s    ECLECTIC    OBSTETitlC's. 

When  a  pregnant  female  is  subject  to  "  frequent  hysterical  attacks  ; 
unaccountable  exuberance  or  depression  of  spirits ;  morbid  aptitude 
to  exaggerate  every  trivial  occurrence  and  attach  to  it  great  import- 
ance; suspicion;  irritability;  or  febrile  excitation;  or,  what  is  still 
more  indicative,  a  soporous  state,  with  very  quick  pulse,  then,"  saya 
Burrows,  "the  supervention  of  delirium  on  labor  must  be  dreaded." 
And  to  these  symptoms  Ramsbotham  adds,  as  a  prominent  forewarn- 
ing, a  great  loss  of  memory. 

PROGNOSIS. — The  more  serious  form  of  puerperal  mania,  is  that 
which  is  manifested  by  a  greater  or  less  degree  of  excitement.  When 
it  occurs  immediately  after  delivery,  with  constant  and  rapid  pulse,  the 
paroxysms  being  furious  and  ungovernable,  it  is  much  more  dangerous 
to  life  than  when  it  occurs  later,  and  with  milder  symptoms.  Free 
evacuations  from  the  bowels  are  favorable,  as  are  likewise  a  decrease 
of  the  pulse,  the  patient  obtaining  some  sleep,  and  not  being  much 
prostrated.  A  rapid  pulse,  increasing  in  frequency,  is  generally  indi- 
cative of  a  fatal  result,  the  mania  being  probably  connected  with  an 
inflammatory  action  of  some  of  the  pelvic  or  abdominal  viscera.  The 
melancholy  form  of  .puerperal  mania  is  more  permanent,  and  more 
difficult  of  removal,  than  the  raving.  "  Mania  is  more  dangerous  to 
life — melancholia  to  reason."  (Gooch.) 

TREATMENT. — To  have  the  patient  placed  in  a  hospital  is,  very 
frequently,  as  the  rule,  the  best  and  only  course  to  pursue ;  yet,  from 
its  after  effects  upon  the  minds  of  the  patient  and  her  friends,  there 
will  always  remain  a  dread  of  a  second  attack  of  insanity ;  to  avoid 
which,  it  is,  in  every  instance,  better  to  attempt  her  cure  at  home, 
advising  the  hospital  only  as  a  dernier  ressort. — We  must  attend  to  the 
symptoms,  as  they  manifest  themselves,  endeavoring  to  overcome  the 
excitable  condition  of  the  brain  and  nervous  system,  without  occa- 
sioning or  allowing  any  great  amount  of  debility  to  ensue.  The 
bowels  must  be  opened  occasionally  by  some  mild,  stimulating  purga- 
tive, and  kept  free,  during  the  intervals,  by  gentle  laxatives.  The 
compound  powder  of  Jalap  will  answer  as  a  purgative.  As  a  lax- 
ative, the  powder  of  Rhubarb  and  Bicarbonate  of  Potassa  may  be 
used,  or  the  compound  syrup  of  Rhubarb  and  Potassa.  If  the  patient 
can  not  be  persuaded  to  take  these,  stimulating  enema  may  be  used, 
as  Castor  Oil,  with  the  compound  tincture  of  Lobelia  and  Capsicum 
added. 

Frequently  an  emetic  is  indicated  at  the  commencement  of  the 
attack,  the  administration  of  which  has  frequently  produced  results 
of  a  decidedly  beneficial  character;  but  it  must  be  recollected  that 


PUERPERAL    MAMA.  695 

they  are  injurious  when  there  is  prostration  of  the  system,  with  a 
feeble,  rapid  pulse,  pale  face,  and  cold  surface. 

Counter-irritation  will  be  found  of  great  value.  The  whole  sur- 
face should  be  bathed  with  a  warm  alkaline  solution  to  which  some 
alcohol  has  been  added,  after  which  a  sinapism  may  be  applied  the 
whole  length  of  the  spinal  column,  together  with  friction  and  stim- 
ulating applications  to  the  inferior  extremities  from  the  hips  down- 
ward. In  connection  with  this,  the  application  of  tepid  or  cold  water 
to  the  head  three  or  four  times  a  day,  as  a  douche,  will  prove  bene- 
ficial ;  or  cold  applications  may  be  constantly  kept  on  the  head. 
When  there  is  much  activity  of  the  circulation,  with  preternatural 
heat  of  the  head,  the  hair  should  be  cut  off,  and  sometimes  leeches  or 
cups  to  the  temples  and  nape  of  the  neck  will  be  advantageous.  The 
sinapisms  may  be  changed  alternately  from  the  spinal  column  to  the 
extremities,  and  vice  versa,  removing  them  when  considerable  redness 
of  the  surface  to  which  they  have  been  applied  is  produced,  or  when 
they  appear  to  augment  the  disease.  An  irritating  plaster,  as,  for 
instance,  the  Cantharideal  Collodion  dropped  on  adhesive  plaster, 
may  sometimes  be  advantageously  applied  to  the  nape  of  the  neck  or 
between  the  shoulders.  This  will  be  more  serviceable  in  the  melan- 
cholic form  of  insanity. 

After  the  bowels  have  been  evacuated,  sedatives  should  be  exhib- 
ited. The  tincture  of  Gelsemium  will  be  found  exceedingly  valuable; 
it  may  be  used  alone,  or  in  combination  with  such  other  agents  as  are 
indicated  in  each  case.  In  some  cases  one  of  the  most  prominent 
symptoms  will  be  drowsiness  or  stupor,  or  a  capillary  congestion. 
Belladonna  will  be  the  indicated  remedy,  under  such  circumstances, 
and  should  be  continued,  in  the  usual  small  dose,  as  long  as  necessary. 
The  tincture  of  Stramonium,  or  of  Hyoscyamus,  may  be  substituted, 
in  some  cases,  for  that  of  the  Belladonna.  Other  agents  may  also  be 
employed  with  benefit,  as,  a  powder  composed  of  Sulphate  of  Quinia, 
one  grain;  Sulphate  of  Morphia,  half  a  grain;  extract  of  Belladonna 
(dried),  one-eighth  of  a  grain;  mix  for  a  dose,  which  may  be  repeated 
every  hour.  Sleep  and  quiet  are  the  patient's  great  restoratives;  and 
every  justifiable  means  should  be  adopted  to  procure  sleep.  Hydrate 
of  Chloral  has  proved  a  safe  and  highly  efficacious  agent.  Chloroform, 
Indian  Hemp,  Bromide  of  Potassium  in  twenty-grain  doses,  and 
medicinal  Hydrocyanic  Acid,  have  likewise  been  serviceable  in  cer- 
tain cases.  In  some  cases,  subcutaneous  injections  of  Morphia  will 
promptly  induce  sleep.  If  ;  he  be  boisterous,  struggling  against  the 


696  KING'S  ECLECTIC  OBSTETRICS. 

attempts  made  to  induce  sleep,  she  should  be  fastened  in  such  a  way 
as  to  keep  her  in  bed,  and  prevent  her  from  exhausting  herself  by 
her  struggles.  As  with  the  preceding  puerperal  maladies,  cleanliness 
will  be  of  great  value;  especially  the  removal  of  offensive  and  putrid 
material  from  the  utero-vaginal  canal  by  injections  of  some  disin- 
fecting fluid. 

The  patient  should  be  kept  in  a  darkened  room,  free  from  noise  or 
disturbance,  and  an  experienced  nurse  should  be  obtained  who  is  ac- 
customed to  attend  such  patients,  and  who  understands  how  to  manage 
their  whims  and  caprices — for  a  scolding,  contradictory,  or  inattentive 
nurse,  will  effect  more  injury  than  benefit,  by  increasing  the  excite- 
ment and  fury  of  the  patient.  If  the  female  be  very  boisterous  and 
unruly,  attempting  violence,  it  may  become  necessary  to  employ  some 
restraint,  as  a  strait  waistcoat,  but  this  must  not  be  used  without  it  is 
absolutely  required;  frequently,  an  observation  to  the  nurse,  in  the 
presence  of  the  patient,  that  this  will  have  to  be  employed,  will  at 
once  calm  the  most  raving  maniac.  She  should  never  be  left  alone, 
and  the  windows  of  the  apartment  which  she  occupies  should  be  well 
secured,  and  all  knives  or  other  dangerous  instruments,  with  which 
she  might  effect  suicide,  or  injure  others,  must  be  removed.  The  diet 
must  be  nutritious,  using  food  of  ready  assimilation,  as,  milk,  solution 
of  gelatin,  white  of  egg,  etc.;  and  should  there  be  much  depression 
of  the  system,  stimulants  will  be  required.  It  is  frequently  the  case 
that  the  patient  will  refuse  to  take  either  food  or  medicine.  A  proper 
amount  of  food  must  be  taken  within  the  twenty-four  hours,  and  the 
medicine  may  frequently  be  concealed  in  it;  but  when  she  obsti- 
nately refuses  food,  a  cold  douche,  if  not  contra-indicated,  a  reference 
to  the  strait  waistcoat,  or  persuasion,  may  succeed  in  causing  her  to 
eat.  Sometimes,  if  left  within  her  reach,  she  will  eat  the  food  when 
under  an>  idea,  probably,  that  she  is  unobserved.  It  is  always  proper, 
when  it  can  be  accomplished,  after  the  severity  of  the  first  attack  has 
subsided,  to  have  the  female  exercise  as  much  as  possible  in  the  open 
air,  but  not  to  such  an  extent  as  to  cause  fatigue.  There  is  frequently 
an  anaemic  condition  of  the  system  in  this  disease,  which  the  practi- 
tioner should  carefully  observe,  and  for  which  some  ferruginous  prep- 
aration will  be  found  to  act  like  a  charm. 

In  the  early  stages  of  puerperal  insanity,  it  is  not  prudent  to  allow 
the  .female  to  see  her  husband,  child,  or  friends,  as  it  generally  proves 
injurious,  by  giving  rise  to  ideas,  or  mental  efforts,  which  increase  the 
cerebral  disturbance;  but,  in  the  passive  or  chronic  stages,  short  and 
distant  interviews  are  frequently  followed  by  an  abatement  of  the 


INTESTINAL    IRRITATION.  697 

mental  derangement.  Aud,  whenever  it  is  deemed  desirable  that  she 
should  see  her  child,  she  must  not  be  permitted  to  handle  it,  lest  in  a 
sudden  maniacal  fit  she  should  destroy,  or  seriously  injure  it. 

In  the  melancholic  form,  nutrition,  anemia,  and  debility,  are  chiefly 
to  be  attended  to;  prescribing  a  good,  nutritious,  easily  digestible  diet, 
moderate  exercise  in  the  clear,  open  air.  chalybeates,  quinine,  and  an 
attention  to  the  skin  and  to  the  alvine  and  renal  discharges.  The 
patient  should  be  placed  under  cheerful,  attractive,  and  pleasing  sur- 
roundings, in  order  to  lessen  the  melancholy  disposition,  while  any 
excitement  of  the  nervous  system  must  be  avoided,  or  be  promptly 
calmed  by  appropriate  means.  Tonics  will  generally  prove  useful  for 
patients  much  enfeebled.  In  both  forms  of  mania,  if  the  mind  can 
be  properly  directed,  it  will  prove  a  valuable  auxiliary  in  the  treat- 
ment. In  one  case,  the  most  desirable  results  followed  the  internal 
use  of  minute  doses  of  Phosphorus  and  Nux  Vomica,  with  full  doses 
of  Phosphate  of  Lime. 

When  there  is  reason  to  anticipate  an  attack  of  mania  at  the  partu- 
rient period,  either  from  a  hereditary  predisposition,  from  insanity  at 
a  former  labor,  or  from  the  symptoms  heretofore  described,  a  proper 
course  of  treatment  should  at  once  be  instituted.  The  bowelSj 
especially,  should  be  kept  regular,  and  no  crude,  indigestible,  or  other 
improper  articles  of  diet  should  be  allowed.  All  sources  of  irritation 
should  be  removed,  the  mind  must  be  kept  free  from  exciting  or 
depressing  influences;  coition  during  the  gestating  period  must  be 
positively  forbidden;  moderate  exercise  must  be  advised,  but  not  to 
the  extent  of  fatigue ;  the  female  should  not  be  allowed  to  remain 
alone,  and  the  company  permitted  to  visit  her  must  be  carefully 
selected,  refusing  admittance  to  those  who  occasion  too  great  a  degree 
of  mirth,  as  well  as  to  those  who  are  fond  of  dispensing  horrible  and 
melancholy  news,  whether  true  or  false;  pleasant,  cheerful,  and  pru- 
dent individuals  only  should  be  selected.  If  the  patient  be  sleepless, 
Bromide  of  Potassium,  Chloral  Hydrate,  Hyoscyamus,  or  other 
hypnotic  agent  may  be  used;  or  subcutaneous  injections  of  the  same; 
and,  in  certain  cases,  nervines  will  be  of  decided  utility,  as,  fluid 
extract  of  Scutellaria,  or  of  Asclepias,  Lupulin,  Pulsatilla,  Gelsemium, 
etc.  Plethora  must  be  overcome  by  diuretics;  anaemia  by  chaly- 
beates; and  debility  by  bitter  tonics  and  such  other  invigorating 
measures  as  may  be  found  serviceable.  The  Parturient  Balm  will  be 
•of  advantage  in  instances  where  symptoms  of  the  trouble  are-  man- 
ifest before  delivery.  Should  there  be  a  constant,  dull,  or  severe 
pain  in  the  head,  cooling  lotions  to  the  head,  sinapisms  to  the  back 


698  KING'S  ECLECTIC  OBSTETRICS. 

of  the  neck,  with  rest  and  quiet,  will,  in  conjunction  with  the  other 
means,  generally  remove  it,  and  prevent  the  attack  at  the  puerperal 
season. 

Females  are  subject  to  a  condition  slightly  resembling  peritonitis, 
and  which  has  been  named  INTESTINAL  IRRITATION,  by  Dr. 
Marshall  Hall,  and  Acute  Tympanites,  by  Dr.  Ramsbotlmm.  It  may 
be  owing  to  some  peculiar  excitement  or  irritation  of  the  lining  mem- 
brane of  the  intestinal  tube,  occasioned  by  a  constipated  condition 
of  the  bowels,  improper  food,  or  irregularities  of  diet,  which,  by 
debilitating  the  muscular  fibers  of  the  intestines,  causes,  soon  after 
delivery,  a  sudden  development  of  gas. 

The  attack  occurs  generally  two  or  three  days  after  delivery,  being 
ushered  in  with  rigors,  which  are  more  or  less  severe,  and  are  suc- 
ceeded by  increased  heat  and  dryness  of  the  skin ;  rapid  pulse,  fuller 
and  firmer  than  in  peritonitis,  or  fluttering  and  tremulous;  tongue 
red,  sometimes  furred;  countenance  changed,  but  not  as  anxious  as  in 
peritonitis;  severe  headache;  intolerance  of  light  and  sound;  constant 
wakefulness;  and  often  delirium.  At  an  early  period  the  abdomen 
swells  rapidly  and  to  an  enormous  extent,  being  very  tense  and  painful, 
and  the  pain  is  aggravated  by  pressure  ;  frequently  the  transverse  colon 
can  be  distinctly  traced.  The  secretion  of  milk  becomes  suspended,  as 
well  as  the  lochia;  the  patient  lies  upon  her  back  in  a  state  of  languor, 
being  averse  to  conversation,  or  any  kind  of  disturbance;  the  legs  are 
usually  drawn  up,  and  the  female  appears  indifferent  to  everything  about 
her.  As  the  disease  progresses,  the  pain,  and  swelling  of  the  abdomen 
increase,  the  tongue  becomes  dry  and  brown,  with  vomiting  of  offensive 
matter,  hiccough,  IOWT,  muttering  delirium,  subsultus  tendinum,  and 
other  symptoms  common  to  the  last  stage  of  fever. 

DIAGNOSIS. — The  principal  distinguishing  mark  between  this 
disease- and  peritonitis,  is  the  period  of  abdominal  enlargement.  In 
peritonitis  the  first  symptom  is  pain,  and  the  swelling  does  not  come 
on  until  the  disease  has  existed  sometime ;  in  the  disease  under  con- 
sideration the  swelling  manifests  itself  first,  and  the  pain  is  subsequent, 
being,  probably,  occasioned  by  the  inordinate  inflation  of  the  intestines, 
together  with  a  morbid  state  of  the  nerves.  In  peritonitis  the  patient 
is  anxious  as  to  the  termination  of  her  disease;  in  the  present  affection 
there  is  a  great  loss  of  nervous  energy,  occasioning  a  complete  state 
of  listlessness. 

PROGNOSIS. — A  subsidence  of  the  tenseness,  swelling,  and  pain 
of  the  abdomen,  with  the  pulse  becoming  more  natural,  the  tongue 
clean  and  more  moist,  the  skin  cool  and  soft,  the  bowels  becoming 


INTESTINAL    IRRITATION.  699 

free  with  expulsion  of  large  quantities  of  wind,  vomiting  ceasing, 
intellect  unimpaired,  a  desire  for  food,  and  an  attention  to  surrounding 
circumstances,  are  indicative  of  recovery. 

TREATMENT. — Should  there  be  any  undigested  food  upon  the 
stomach  an  emetic  may  be  administered,  to  be  followed  by  a  purgative. 
The  compound  powder  of  Jalap  may  be  given  to  produce  free  evacu- 
•arion  of  the  bowels;  at  the  same  time  an  injection  of  hot  water  may 
be  given,  to  aid  the  evacuation,  as  well  as  to  relieve  the  pain.  If  the 
patient  be  very  feeble,  the  purgative  may  be  omitted,  using  the  injec- 
tion instead,  as  may  be  required. 

After  the  bowels  have  been  freely  relieved,  Nux  Vomica  will  be 
called  for  in  many  cases;  the  indication  will  be  the  broad,  expression- 
less tongue',  nausea,  and  pain  in  the  bowels.  Dioscorea  is  the  remedy 
where  there  are  cramps,  and  a  pain  like  colic.  Podophyllin  should 
be  given  in  case  the  tongue  shows  the  heavy  coat  at  base.  Much 
benefit  will  also  be  derived,  in  some  cases,  from  the  use  of  the  tinct- 
ure of  Xunthoxylum.  These  agents  allay  irritation,  aid  in  expelling 
the  gas,  and  gradually  restore  the  tone  of  the  intestines.  Cloths  wet 
with  hot  water,  or  hot  fomentations  of  Hops  and  Tansy,  or  other 
bitter  herbs,  will  prove  highly  valuable  when  applied  over  the 
abdomen. 

The  Oil  of  Turpentine,  exhibited  externally  and  internally,  has 
been  highly  extolled  in  this  disease.  Externally,  it  is  to  be  applied 
over  the  surface  of  the  abdomen ;  internally,  one  or  two  fluid  drachms, 
mixed  with  the  white  of  an  egg,  may  be  given,  and  the  dose  repeated 
every  four  hours ;  or,  if  rejected  by  the  stomach,  an  ounce  of  it  may 
be  injected  into  the  rectum. 

Should  any  inflammatory  symptoms  be  present,  they  must  be 
combated  by  the  means  already  explained. 

The  patient  should  be  kept  quiet,  her  room  being  somewhat  dark- 
ened, and  no  visitors  should  be  permitted  to  enter.  After  the  evacu- 
ation of  the  bowels,  when  the  swelling  begins  to  subside,  a  nutritious, 
easily-digested  diet  should  be  allowed,  with  some  stimuli  if  required. 
Tonics  may  also  be  exhibited.  I  know  of  no  better  agent  to  rapidly 
restore  the  tone  of  the  intestines,  after  all  the  dangerous  symptoms 
have  been  removed,  than  the  continued  use  of  small  doses  of  Nux 
Vomica.  Pulv.  Hydrastis  and  Bismuth  answers  a  very  good  purpose 
in  some  cases  also. 


700  KING'S  ECLECTIC  OBSTETRICS. 


CHAPTER    LI. 

INFLAMMATION    OF    THE    BREASTS MAMMARY    ABSCESS EPHEM- 
ERAL   FEVER WEED — MILIARY    FEVER — SORE 

MOUTH    OF    NURSING    WOMEN. 

INFLAMMATION  OF  THE  BREASTS,  mammary  afacet*,  01 
mammitis,  is  of  frequent  occurrence  among  nursing  women ;  it  may 
happen  at  any  period  of  lactation,  but  is  most  commonly  met  with 
during  the  first  month  after  delivery.  At  first,  the  inflammation  is 
usually  limited  to  a  circumscribed  spot,  but  continues  to  extend  into 
the  surrounding  parts,  until  the  whole  breast  becomes  more  or  less 
involved;  occasionally,  the  whole  breast  may  be  affected  from  the 
beginning,  and,  sometimes,  both  breasts  become  inflamed  simultane- 
ously. There  is  a  strong  tendency  to  suppuration  in  inflammation  of 
the  mamma,  which  is  often  very  difficult  to  prevent;  and  when  the 
constitution  suffers  therefrom,  as  by  anorexia,  nausea,  feeble,  rapid 
pulse,  great  emaciation,  excessive  nervous  irritability,  and  mental 
anxiety  and  despondency,  together  with  chills,  exhausting  sweats,  etc., 
we  are  by  no  means  astonished  that  delirium  of  a  wild  character, 
closely  resembling  puerperal  mania,  may  sometimes  be  manifested. 

This  affection  may  be  caused  by  an  increased  accumulation  of  milk 
within  the  lactiferous  tubes,  occasioned  by  the  mother  not  allowing 
her  child  to  suck,  on  account  of  tender  and  excoriated  nipples,  or, 
perhaps,  because  she  absents  herself  from  her  child,  frequently  and  at 
long  periods,  in  order  to  enjoy  parties  and  places  of  amusement,  thus 
neglecting  to  give  to  the  distended  breasts  the  relief  they  require.  A 
neglect  of  this  kind,  repeated  several  times,  will  readily  induce  an 
abnormal  condition  of  the  glands.  Epidemic  (or  endemic)  influence 
appears  to  be  a  predisposing  cause.  The  disease  may  also  be  produced 
by  cold,  and  this  is  undoubtedly  a  common  exciting  cause.  It  may 
likewise  follow  mechanical  injuries,  such  as  blows,  bruises,  compression 
from  tight  lacing,  etc.,  when  the  breasts  are  distended  with  milk,  and 
may  also  be  induced  by  strong  mental  emotions.  All  females  are 
subject  to  it,  but  those  of  a  strumous  diathesis,  or  who  are  delicate  and 
feeble,  are  especially  so.  It  is  more  common  to  primi  parse;  but,  many 
females  suffer  from  it  after  each  confinement. 

SYMPTOMS. — The  inflammation  may  be  limited  to  the  subcuta- 
neous areolar  tissue;  to  the  gland;  to  the  areolar  tissue  beneath  the 


INFLAMMATION    OF   THE    BKEASTa.  701 

gland;  or,  may  extend  to  two  or  all  of  these  combined.  Generally,  the 
first  symptoms  experienced  are  more  or  less  severe  rigors,  followed 
by  fever;  a  shooting  pain  in  the  breast  is  complained  of  by  the 
patient,  which  is  aggravated  by  pressure,  and  accompanying  which 
there  is  a  gradual  swelling  of  the  organ.  Upon  examining  the  breast 
at  an  early  period,  a  circumscribed  hardness  may  be  observed,  within 
which  the  pain  is  located,  and  the  skin  over  which  presents  a  natural 
appearance.  As  the  disease  progresses  the  swelling  becomes  more 
extensive,  the  pain  more  severe,  the  skin  hot  and  shining,  and  of  a 
dusky-red  color,  and  finally  the  swelling  becomes  soft  and  slightly 
oedematous,  with  more  or  less  marked  fluctuation,  indicative  of  the 
formation  of  pus.  The  symptoms  now  increase  in  severity;  the  patient 
becomes  fretful  in  consequence  of  the  severe  pain,  distressing  shiver- 
ings,  want  of  sleep,  and  nocturnal  perspirations,  all  of  which  occasion 
a  gradual  loss  of  appetite,  strength,  and  flesh.  Sometimes  nausea  is 
present,  and  not  unfrequently  an  obstinate  diarrhea. 

The  pain  is  more  severe  in  proportion  to  the  extent  and  depth  to 
which  the  gland  is  involved.  If  the  inflammation  be  superficial,  the 
pus  is  laudable ;  if  it  extend  deeply,  there  is  always  sloughing  of 
considerable  magnitude  present,  and  death  from  hemorrhage  has 
occurred  from  the  blood-vessels  of  the  part  becoming  involved  in  the 
destructive  process.  The  suppuration  ensues  more  rapidly  when 
the  inflammation  is  superficial,  or  in  the  cellular  substance  under 
the  skin. 

DIAGNOSIS. — The  subcutaneous  variety  of  mammitis  presents  the 
usual  manifestations  of  phlegmonous  inflammation;  if  suppuration 
ensues,  fluctuation  will  be  detected,  and  the  part  at  which  the  abscess 
points  will  become  thin  and  dark  colored,  with  generally  but  one 
abscess — when  the  gland  itself  is  attacked,  and  which  is  more  commonly 
the  case,  the  pain  will  be  more  severe,  and  of  a  lancinating  character; 
there  will  be  more  constitutional  disturbance,  the  portion  of  gland 
involved  becomes  indurated,  suppuration  ensues  rnore  slowly,  and 
numerous  abscesses  are  formed.  In  the  deeper-seated  variety,  the  pain 
is  located  more  deeply  and  is  aggravated  by  pressure  upon  the  gland, 
though,  unless  the  subcutaneous  areblar  tissue  be  involved,  there  will 
be  no  pain  upon  touching  or  sljghtly  pressing  upon  the  surface  of  the 
breast;  the  inflammation,  which  is  generally  circumscribed  in  the  former 
varieties,  tends  to  become  diffuse;  and  when  suppuration  occurs,  the 
patient  experiences  chills  and  exhausting  sweatings,  the  surface  of  the 
breast  is  smooth  and  uniform,  without  any  induration,  and,  when  much 
enlarged,  there  is  an  unpleasant  sensation  of  distension  and  weight. 


702  KING'S  ECLECTIC  OBSTETRICS. 

When  these  varieties  exist  together  the  symptoms  common  to  each 
will  be  present,  according  to  the  variety  and  the  severity  of  the 
inflammation. 

PROGNOSIS. —  Mammitis,  when  not  properly  treated,  generally 
terminates  in  suppuration;  the  character  of  the  abscess,  and  of  the 
constitutional  symptoms,  depending  upon  the  seat  and  nature  of  the 
inflammation.  In  the  subcutaneous  variety,  if  resolution  be  m  t 
effected,  suppuration  will  ensue  in  from  five  to  ten  days,  the  abscc-scs 
from  which  may  be  cured  in  from  seven  to  twenty-one  days.  When 
the  gland  is  attacked,  the  duration  of  the  disease  is  much  longer,  aiul 
suppuration  occurs  very  slowly,  forming  abscesses,  which  are  develnpe-1 
one  after  another  at  different  intervals  of  time,  and  which  may  continue 
even  under  the  most  appropriate  treatment  from  two  to  four,  and 
occasionally,  even  to  eight  months. 

When  the  tissue  between  the  gland  and  the  walls  of  the  thorax  is 
attacked,  in  most  cases,  we  may  not  be  aware  of  it  until  the  suppura- 
tion has  manifested  itself;  and  even  when  the  diagnosis  is  readily  made 
out  at  an  early  period,  it  is  very  difficult,  if  not  impossible,  to  prevent 
suppuration;  and  the  abscess  continues  a  much  longer  time  than  in 
the  other  varieties,  generally  discharging  through  a  number  of  fistulous 
canals.  I  have  seen  cases  in  which  from  extension  of  the  disease,  the 
whole  breast  has  sloughed  away,  giving  rise  to  a  large,  open,  as  well 
as  fistulous  abscess,  discharging  most  profusely,  and  continuing  for  a 
period  of  two  and  even  three  years.  Lactation  is  not  always  arrested; 
this  depends  entirely  upon  the  extent  of  the  sloughing,  and  the  peculiar 
tissues  involved,  and  is  more  common  with  the  variety  in  which  the 
gland  itself  is  implicated.  Sometimes,  the  structural  lesion  is  such  as 
to  arrest  the  function  of  lactation  for  a  considerable  time,  but  which 
becomes  eventually  restored;  at  other  times  the  loss  of  this  function 
may  remain  permanently. 

This  disease  is  more  unfavorable  to  patients  of  a  strumous  habit, 
and,  though  it  rarely  proves  fatal,  yet  it  requires  prompt  and  energetic 
treatment.  It  is  frequently  of  tedious  and  difficult  cure,  and  has  been 
known  to  arouse  a  dormant  and  inactive  predisposition  to  disease,  into 
a  fatal  activity. 

TREATMENT. — The  indication  for  treatment  is  to  promote  reso- 
lution ;  but,  if  the  disease  has  continued  for  two  or  three  days,  with 
considerable  heat  and  pain,  resolution  can  seldom  be  effected,  and  then, 
means  must  be  adopted  to  promote  suppuration. '  Suppuration  usually 
•occurs  in  ten  or  twelve  days,  seldom  sooner. 


INFLAMMATION    OF    THE    BREASTS.  703 

In  order  to  prevent  the  inflammation  from  terminating  in  suppura- 
tion, the  treatment  must  be  active  and  persistent.  It  is  well,  in 
some  cases,  to  administer  a  mild  cathartic  in  the  beginning.  The 
proper  sedative  should  now  be  selected,  which  will  usually  be 
Aconite ;  to  this  Phytolacca  should  be  added,  as  a  specific,  in  gland- 
ular inflammation.  About  ten  drops  of  each  should  be  prescribed, 
and  given  in  teaspoonful  doses  every  hour.  In  the  subcutaneous 
and  glandular  varieties,  the  breast  should  be  painted  two  or  three 
times  a  day,  with  some  stimulating  preparation;  I  generally  employ 
a  liniment  made  of  equal  parts  of  Oil  of  Cajeput,  Oil  of  Sassafras, 
Olive  Oil  and  Camphor.  After  applying  this,  a  warm  poultice  or 
fomentation  may  be  applied,  and  which  should  be  changed  two  or 
three  times  a  day,  at  the  periods  of  bathing  with  the  liniment. 

Although  I  have  just  recommeded  the  application  of  a  fomentation 
or  poultice  to  the  breast,  it  is  only  because  others  have  frequently 
used  them  with  advantage.  Prof.  King  recommends  the  following 
ointment,  which  may  be  applied  immediately  after  having  bathed  the 
breast  with  the  above  liniment :  Take  of  Castile  Soap  six  ounces,  good 
Lard  four  ounces,  yellow  Beeswax  two  ounces ;  finely  cut,  or  shave  the 
soap,  add  to  it  the  other  articles,  and  melt  the  whole  together  by  means 
of  a  moderate  heat.  When  thoroughly  melted  and  incorporated, 
remove  the  vessel  containing  them  from  the  fisre,  and  when  nearly 
cool,  add  gradually  three  fluidounces  of  Jamaica  Spirits,  in  which 
three  drachms  of  Camphor  have  been  previously  dissolved.  Continue 
stirring  the  mixture  until  it  is  cold. 

Prof.  King  speaks  of  its  use  as  follows : 

This  ointment  has  been  used  with  success  in  every  case  where  it 
was  applied  at  an  early  stage,  or  previous  to  suppuration ;  it  removes 
all  pain  and  swelling  in  from  twelve  to  thirty-six  hours,  according  to 
the  duration  of  the  disease.  I  have  frequently  found  it  efficacious  in 
cases  where  the  patient  had  suffered  severely  for  twenty-four  hours, 
and  when  I  had  every  reason  to  believe  that  the  suppurative  stage  had 
actually  commenced.  I  employed  it  with  constant  success  for  nearly 
fourteen  years  before  having  made  it  known  to  the  profession. 

The  manner  of  using  it  is  as  follows :  Cut  a  piece  of  linen  in  a  cir- 
cular form,  of  the  size  of  the  whole  breast,  leaving  an  aperture  in  the 
center  sufficiently  large  for  the  nipple  to  pass  through.  Then  soften 
a  sufficient  quantity  of  the  ointment  by  a  gentle  heat,  and  spread  it  on 
the  linen.  Apply  this  over  the  breast,  as  warm  as  can  be  borne ;  at 
intervals  of  four  or  six  hours,  remove  it,  soften  it  as  before,  and 
reapply  it  to  the  breast  immediately  after  having  bathed  it  with  the 


/04  KING'S    ECLECTIC    OI5STETRICS. 

stimulating1  liniment.  A  fresh  application  of  the  ointment  will  be 
needed  only  once  in  every  twenty-four  hours ;  the  patient  should  be 
kept  quiet  in  bed,  and  the  breast  should  be  carefully  supported  by  a 
bandage,  or  some  similar  means.  Other  local  applications  have  been 
advised,  as:  carefully  painting  the  inflamed  surface  of  the  breast  with 
tincture  or  solution  of  Iodine,  solution  of  Belladonna  extract,  etc., 
but  I  have  never  used  them  in  this  malady. 

During  the  first  stage  of  the  disease  more  especially,  it  is  of  great 
importance  to  keep  the  breasts  as  empty  as  possible,  and  if  this  can 
not  be  effected  by  the  infant,  other  means  must  be  resorted  to,  as,  some 
older  person  accustomed  to  the  business,  a  young  pup,  or  an  exhaust- 
ing pump.  And  any  febrile  symptoms  may  be  mitigated,  as  well  as 
pain  and  nervous  irritability,  by  the  exhibition  of  the  compound 
powder  of  Ipecacuanha  and  Opium,  Sp.  Trs.  of  Aconite  or  Verat- 
rum,  with  Phytolacca.  When  the  pain  is  excessivelv  severe  and 
the  febrile  symptoms  run  high,  it  will  be  better  to  avoid  feeding  the 
infant  at  all  from  the  affected  breast,  and,  in  some  cases,  it  will  be 
proper  not  to  annoy  the  mother  and  increase,  her  sufferings  by 
requiring  her  to  give  it  suck,  but  to  feed  it  for  a  short  time  in  some 
other  way ;  if  possible,  have  a  wet  nurse  employed.  In  the  glandular 
and  subglandular  varieties  especially,  Sulphate  of  Quinia  will  be 
found  a  most  valuable  agent,  mitigating  the  constitutional  symptoms, 
and  often  preventing  suppuration ;  it  should  be  given  so  as  to  effect  a 
prompt  influence  upon  the  system,  which  should  be  kept  up  for  some 
length  of  time. 

If,  however,  matter  should  form,  then  the  employment  of  poultices 
to  hasten  its  progress  will  be  found  of  considerable  value.  And  now, 
the  infant  should  not  be  permitted  to  use  the  milk  of  the  affected 
breast  any  longer,  because,  with  the  milk,  which  has  lost  its  nutritive 
qualities,  it  may  be  injured  by  the  reception  of  pus  into  its  stomach ; 
the  milk  must  be  evacuated  by  other  means.  Fresh  Poke-root  roasted 
in  hot  ashes,  in  the  same  manner  as  the  potato,  until  it  is  soft,  then 
mashed  and  applied  over  the  breast  as  a  poultice,  will  materially 
forward  the  suppurative  stage,  though  its  action  will  produce  more 
suffering  than  the  poultices  ordinarily  employed  for  such  purpose. 
The  addition  of  pulverized  Lobelia,  moistened  with  a  mixture  of  warm 
water  and  vinegar,  to  the  roasted  Poke-root,  will  materially  enhance  its 
value.  Flaxseed,  Elm,  or  any  of  the  common  non-irritating  agents  • 
may  be  used  for  the  poultice.  In  connection  with  the  local  applica- 
tions, the  internal  administration  of  Phytolacca  with  the  sedative 
should  be  continued,  and  will  usually  be  followed  by  prompt  and 
favorable  results.  It  has  been  stated  that  if  this  treatment  bv  Poke- 


INFLAMMATION    OF    THE    BREASTS.  705 

root,  internally  and  externally,  be  commenced  at  an  early  period  of 
the  attack,  suppuration  will  be  prevented,  and  the  disease  will  termi- 
nate by  resolution,  even  in  the  deeper- seated  varieties. 

When  suppuration  has  occurred,  the  following  rules  should  be 
observed : 

"  If  the  abscess  is  placed  superficially,  or  on  the  anterior  surface  of 
the  breast,  and  progresses  with  rapidity,  not  causing  an  undue  degree 
of  suffering,  it  will  be  better  not  to  interfere  with  it,  but  to  allow  it  to 
take  its  natural  course. 

"  If  it  be  deeply  situated,  progressing  slowly,  giving  rise  to  severe 
local  sufferings,  and  is  attended  with  a  high  irritative  fever,  profuse 
perspiration,  and  want  of  rest,  much  time  will  be  saved,  as  well  as 
considerable  suffering,  by  opening  the  abscess  at  the  proper  period, 
with  a  probe  or  lancet,  and  permitting  the  pus  to  escape,"  being  care- 
ful however,  not  to  be  in  such  a  hurry  as  to  make  an  opening  before 
pus  has  formed.  And  always,  in  opening  the  abscess,  carry  the 
incision  parallel  with  the  lactiferous  vessels,  so  as  to  avoid  dividing 
them,  as  much  as  possible.  In  all  cases,  it  will  be  well  to  introduce  a 
tent  into  the  openjng  to  prevent  it  from  closing  before  the  pus  has 
been  entirely  discharged.  • 

"  If  there  is  a  thick  covering  over  the  abscess,  it  is  improper  to 
penetrate  it  with  the  lancet,  because  the  opening  will  not  succeed  in 
establishing  a  free  discharge  of  matter,  for,  as  the  aperture  closes  by 
adhesion,  the  accumulation  of  matter  proceeds,  and  ulceration  will 
still  continue.  On  this  account,  the  opening  should  be  made  where 
the  matter  is  most  superficial,  and  where  the  fluctuation  is  distinctly 
perceptible,  and  its  size  should  be  proportioned  to  its  depth."  Also, 
keep  it  open  by  the  introduction  of  a  tent. 

"  When  the  abscesses  are  very  deep,  with  several  sinuses,  the  best 
mode  of  treatment,  is  to  inject  into  them  a  solution  of  two  or  three 
drops  of  strong  Sulphuric  acid  in  a  fluidounce  of  Rosewater;  and  this 
may  likewise  be  applied  on  folds  of  linen  cloth  over  the  bosom,  by 
which  the  secretion  of  milk  is  checked,  and  adhesion  is  produced." 
(Sir  A.  Cooper.}  .,  , 

If  the  ulcer  does  not  readily  heal,  or  assumes  an  indolent  character, 
apply  some  sesqui-carbonate  of  Potassa  to  it,  and  dress  iit  -with  the  red 
oxide  of  Lead  plaster,  or  the  compound  Lead  ointment,  treating  it 
similar  to  ulcers  on  other  parts. 

Should  there  be  a  troublesome  oozing  of  blood ,  £r.om  the  ,wound 
made  by  the  lancet,  in  opening  the  abscess,  it  must  be  treated  by  the 
application  of  dry  lint,  with  sufficient  compression. 
45 


706  KING'S  ECLECTIC  OBSTETRICS. 

In  the  inflammatory  stage,  the  diet  must  be  light  and  non-stimu- 
lating; during  the  suppurative  discharge,  a  nourishing  diet  should  be 
used,  and  to  support  the  strength  and  aid  in  the  formation  of  healthy 
pus,  Port  wine  and  Cinchona,  or  the  compound  wine  of  Comfrey, 
will  be  required.  If  there  is  exhaustion  with  considerable  irrita- 
bility of  the  system,  Morphia  and  Quinia  combined,  will  be  found 
advantageous. 

Beside  MILK  FEVER,  which  has  been  referred  to  on  another  page, 
there  are  two  other  forms  of  fever  which  may  be  occasionally  met 
with  in  practice.  One  is  termed  EPHEMERAL  FEVER,  or 
WEED,  and  is  more  especially  met  with  in  cold,  moist  weather, 
among  those  who  reside  in  low,  marshy  places,  or  in  the  neighbor- 
hood of  stagnant  ditches.  It  may  likewise  be  occasioned  by  cold, 
indigestion,  constipation,  fatigue,  mental  agitation,  want  of  rest,  and 
improper  food.  It  appears  usually  in  from  six  to  nine  days  after 
delivery,  and  seldom  continues  over  twenty-four  or  forty-eight  hours, 
whence  its  name,  ephemeral.  It  commences  with  severe  and  long- 
continued  rigors,  succeeded  by  heat  and  profuse  perspiration.  During 
the  shivering  there  will  be  pain  in  the  back  and  various  parts  of  the 
system,  shrunken  features,  eyes  hollow,  skin  dry  and  harsh,  with  the 
integuments  at  the  fingers'  ends  livid  and  corrugated,  thirst,  rapid  and 
perhaps  irregular  pulse,  or  feeble  and  indistinct;  and  various  other 
distressing  symptoms,  which  increase  in  severity  as  the  rigors  are 
about  passing  off.  The  hot  stage  is  characterized  by  a  throbbing  of 
the  temples ;  great  heat  of  the  surface ;  flushed  face ;  severe  headache, 
generally  referred  to  the  forehead  and  eyeballs;  soreness  of  the  breasts 
and  of  the  abdomen ;  rapid,  full,  hard,  and  firm  pulse ;  and  a  dimi- 
nution of  the  various  secretions,  with  occasional  delirium.  This  is 
followed,  after  a  longer  or  shorter  time,  by  a  profuse  perspiration, 
which  appears  first  on  the  forehead,  neck,  and  chest,  and  which  is 
succeeded  by  an  abatement  of  the  fever,  and  an  amelioration  o£  all 
the  previous  symptoms. 

This  disease  may  be  mistaken  for  puerperal  peritonitis;  but  the 
violence  and  long  continuance  of  the  rigors,  the  absence  of  marked 
abdominal  tenderness  on  pressure,  and  the  very  profuse  perspiration 
which  is  followed  by  relief,  will  enable  us  to  distinguish  it,  as  well  as 
the  absence  of  a  return  of  the  paroxysms.  It  is  seldom  a  dangerous 
disease,  unless,  by  improper  management,  it  be  allowed  to  pass  into  a 
continued  or  intermittent  fever. 


EPHEMERAL,    FEVER    OR    WEED.  707 

TREATMENT.— The  indications  of  treatment  are  to  shorten  the 
various  stages  of  the  disease  as  much  as  possible.  During  the  cold 
stage,  apply  warmth  to  the  surface,  as  bottles  of  warm  water,  or  warm 
bricks,  etc.,  to  the  feet,  knees,  thighs,  and  axillae,  and  warm  flannels 
over  the  stomach  and  abdomen;  in  addition  to  which,  warm  drinks 
and  cordials  may  likewise  be  given;  and,  as  the  case  may  require, 
adopting  other  means  similar  to  those  which  would  be  employed  in 
the  cold  stage  of  ague.  As  the  bowels  are  frequently,  constipated,  an 
active  purgative  should  be  administered  either  in  this  or  the  subse- 
quent stage;  sometimes  an  emetic  will  prove  advantageous. 

In  the  hot  stage,  the  surface  should  be  bathed  with  warm  water, 
and  the  proper  sedative  administered;  in  some  cases  Sulphate  of 
Quinia  may  be  given,  in  three-grain  doses,  for  a  day  or  two.  If  there 
is  much  nervous  irritability,  Pulsatilla  or  Gelsemium  will  be  found 
very  beneficial  agents;  and  these  may  be  continued  for  some  days 
after  the  cessation  of  the  disease,  to  allay  the  irritability  and  lessen 
the  disposition- to  any  secondary  attack. 

In  the  sweating  stage,  the  Sulphate  of  Quinia  may  be  continued 
alone,  or  in  conjunction  with  Priissiate  of  Iron;  and  the  patient 
should  use  some  of  the  tonics;  or  small  doses  of  the  Aromatic 
Sulphuric  Acid  will  frequently  overcome  the  trouble. 

The  several  symptoms  which  may  present  during  each  stage,  must 
be  met  by  measures  similar  to  those  employed  when  they  occur  in 
other  febrile  affections.  After  the  paroxysm  has  ceased,  the  diet  should 
be  nutritious,  with  stimulants  if  there  be  much  depression.  Exposure 
to  cold  should  be  guarded  against,  or  any  other  exciting  cause  of  the 
disease;  and  it  should  be  ascertained  by  a  careful  examination  whether 
any  derangement  of  the  uterine  system  exists,  that  it  may  be  promptly 
subdued. 

The  other  febrile  affection  referred  to  above,  is  termed  MILIARY 
FEVER:  it  is  still  more  rarely  met  with  than  the  preceding,  though 
in  former  days  it  was  quite  common,  and  was  considered  a  formid- 
able disease.  It  may  occur  as  a  primary  affection,  and  independent 
of  the  parturient  state;  but  more  usually  it  appears  as  a  symptom 
connected  with  puerperal,  milk,  or  ephemeral  fevers,  especially  in 
those  cases  where  perspiration  is  permitted  to  become  too  profuse. 
Females  of  debilitated  constitutions  are  more  subject  to  it  than 
others.  It  generally  occurs  between  the  second  and  twelfth  day  of 
delivery,  and  may  be  excited  by  fatigue,  relaxation,  impure,  over- 
heated air,  stimulants,  rich  or  improper  food,  excessive  evacuations, 
constipation,  and  personal  unclean liness. 


708  KING'S  ECLECTIC  OUSTETUICS. 

It  commences  with  chills,  succeeded  by  fever,  and  perspiration  of 
an  acid,  penetrating  odor.  There  is  sickness  and  languor,  with  a  hot 
skin,  frequent  pulse,  depressed  spirits  or  great  anxiety  of  mind,  a  great 
weight  about  the  chest,  severe  headache,  dull  and  watery  or  inflamed 
eyes,  with  throbbings  within  the  orbits,  tongue  furred  white  with 
raised  papillae  and  red  edges,  ringing  in  the  ears,  and  occasionally 
aphthous  ulcerations  of  the  mouth  and  fauces.  The  lochial  and  lac- 
tiferous secretions  are  diminished  or  suppressed,  and  a  pricking  or 
itching  of  the  surface  is  generally  complained  of;  occasionally  there 
is  a  sensation  of  numbness  in  the  extremities.  The  perspiration  is 
usually  followed  by  no  mitigation  of  the  symptoms.  After  these 
symptoms  have  continued  for  a  few  days,  the  skin  begins  to  feel  rough 
like  the  cutis  anserina,  and  in  a  short  time  the  eruption  appears  about 
the  forehead,  neck,  and  breast,  from  whence  it  gradually  extends  to 
the  trunk  and  extremities :  it  rarely  affects  the  face.  It  appears  in  the 
form  of  small,  red,  generally  distinct  vesicles,  about  the  size  of  millet- 
seed,  having  a  red  or  inflammatory  appearance  surrounding  their  base. 
In  a  few  hours  the  vesicles  assume  a  white  or  yellow  appearance,  from 
the  change  effected  in  the  lymph  contained  in  them,  and  in ;a  few  days 
they  dry  up,  and  the  crusts  fall  off  in  small  branny  scales.  The  erup- 
tion, unless  the  disease  be  primary,  seldom  affords  any  relief  to  the 
symptoms,  and  may  occur  frequently  and  irregularly,  should  the  fever 
and  perspiration  continue.  Occasionally,  the  eruption  has  been  met 
with  where  but  little  or  no  fever  was  present.  The  disease  is  seldom 
serious,  unless  the  perspiration  be  suddenly  checked,  or  the  eruption 
recede,  under  either  of  which  circumstances  fatal  results  may  ensue. 

The  disease  may  be  determined  by  the  character  of  the  tongue,  the 
oppression  at  the  chest,  and  the  peculiar,  strong,  and  sour  smell  of  the 
perspiration. 

TREATMENT. — Keep  the  room  well  ventilated  and  cool,  gradually 
lessening  the  amount  of  bedclothes,  but  being  extremely  careful  not  to 
allow  the  patient  to  "catch  cold."  Give  laxatives  to  keep  the  bowels 
regular,  and  when  there  is  derangement  of  the  stomach,  an  emetic  may 
be  useful.  The  drink  of  the  patient  should  be  cold  and  acidulated; 
Rhus  Tox.  should  here  be  given  in  small  doses,  together  with 
Aconite.  Fowler's  Solution  and  Apis  will  be  useful  also  in  some 
cases,  as  well  as  small  doses  of  Iris.  Sulphate  of  Quinia  will  be 
found  of  much  service  during  convalescence. 

On  the  abatement  of  the  febrile  symptoms,  the  diet  may  be  im- 
proved and  mild  tonics  employed.  Should  there  be  aphthous  ulcer- 
ations,  they  may  be  washed  or  gargled  with  a  solution  of  fluid 


SORE    MOUTH    OF    NURSING    WOMEN.  709 

Hydrastis,  or  Borax  water  may  answer  the  purpose.  If  the  disease 
accompanies  other  affections,  especial'  attention  must  be  directed 
toward  the  treatment  of  these,  for  the  secondary  difficulty  will  con- 
tiryie  more  or  less  severe  until  the  primary  one  is  subdued. 

Women  who  suckle,  or  who  have  advanced  to  the  latter  months  of 
pregnancy,  are  sometimes  affected  with  a  sore  mouth  peculiar  to  them- 
selves, somewhat  resembling  follicular  stomatitis,  or  follicular  inflam- 
mation of  the  mouth;  other  females  and  men  being  exempt  from 
it  It  is  generally  known  as  the  SORE  MOUTH  OF  NURSING 
WOMEN  (Stomatitis  Maternd).  The  most  robust  constitution,  or  the 
sickjy  and  delicate,  are  indiscriminately  attacked  by  it;  those,  how- 
ever, of  costive  habits,  dyspeptic  symptoms,  and  hepatic  affections, 
seem  to  be  more  liable  to  its  attacks  than  others.  And  when  there  is 
a  tendency  to  phthisis,  or  some  constitutional  disease,  the  debility 
produced  by  it  is  of  a  much  more  serious  nature,  than  in  vigorous  and 
sound  systems.  I  have  frequently  met  with  it  in  females  who  were 
liable  to  attacks  of  erysipelas,  and  also  those  whose  constitutions  had 
been  injured  by  the  use  of  mercurials.  If  this  disease  is  allowed  to 
go  on  for  any  length  of  time  without  being  relieved,  the  morbid 
irritation  of  the  tongue  and  fauces  extends  to  the  stomach  and  bowels, 
in  which  case  it  is  apt  to  prove  fatal.  I  have  known  the  disease  to 
terminate  in  death  during  the  third,  fourth,  and  fifth  puerperal  week, 
even  after  the  child  had  been  kept  from  the  breast. 

The  children  of  females  laboring  under  this  affection  are  generally 
healthy  and  robust,  being  well  supplied  with  milk,  the  secretion  of 
which  is  commonly  abundant  until  the  last  stages,  when  the  patient 
being  reduced  by  starvation,  this  secretion  fails.  The  means  usually 
employed  for  common  sore  mouth,  or  follicular  inflammation,  will  not 
effect  any  benefit  in  this  disease,  unless  it  be  very  mild  ;  and,  in  many 
instances,  an  energetic  treatment  must  be  pursued,  or  the  patient  will 
die.  Death  has  taken  place  within  a  month  from  the  appearance  of 
the  disease,  and,  again,  patients  have  lingered  for  three  or  four  months 
before  the  fatal  termination.  It  is  a  singular  malady,  nearly  always 
disappearing  upon  weaning  the  child;  yet  weaning  is  not  always 
necessary,  nor  is  it  at  all  desirable,  as  there  is  a  greater  disposition  to 
a  return  of  the  disease  at  every  future  accouchment,  than  in  those 
cases  where  proper  treatment  has  effected  a  cure,  and  restored  the 
constitution  to  its  usual  normal  condition.  It  must  be  recollected, 
that  in  patients  who  have  been  cured  of  this  disease,  there  will  exist  a 
strong  tendency  to  its  return  from  slight  causes,  at  least  until  the 


710  KING'S  ECLECTIC  OBSTETRICS. 

child  is  weaned  ;  as,  from  exposures  to  cold,  fatigue,  indigestible  diety 
etc.,  and  which  in  consequence,  must  be  carefully  guarded  against. 

This  disease  appears  to  depend  on  gastric  and  hepatic  derangement, 
in  connection  with  a  vitiated  state  of  the  blood,  and  is  more  common 
to  those  subject  to  erysipclatous  affections,  or  of  strumous  diathesis. 

SYMPTOMS. — The  accession  of  the  disease  is  often  very  rapid 
from  apparent  health — extremely  so :  within  three  hours  after  seeing 
the  patient  in  health,  perhaps  actively  engaged  in  household  matters, 
and  not  suffering  from  any  unusual  irregularity  of  the  stomach  and 
bowels,  she  will  be  found  with  a  scalding  of  the  tongue  and  fauces. 
and  unable  to  converse  or  take  food.  The  first  sensation  is  uniformly 
described  by  the  patient  as  a  severe  scalding  of  the  tongue,  with  pain, 
at  times  intense.  There  is  also  a  peculiarity  of  the  tongue,  its  color, 
especially  in  the  severer  instances,  being  pink;  and  its  edges  and  the 
roof  of  the  mouth  have  a. deeper  hue  of  this  color,  often  accompanied 
with  a  most  profuse  watery  discharge  from  the  mouth,  extremely  hot, 
so  much  so  as  to  give  a  scalding  sensation  to  the  face  when  passing 
over  it.  The  appetite  is  usually  very  good,  often  ravenous,  but  no 
food  or  drink,  except  the  blandest,  can  be  taken  into  the  mouth, 
without  producing  more  or  less  intense  pain :  the  food  must  be  of  a 
mucilaginous  or  farinaceous  character.  After  a  continuance  of  this 
state  of  the  mouth  for  a  few  days  or  weeks,  slight  ulcerations  on  the 
end  or  edges  of  the  tongue  manifest  themselves,  as  also  about  the 
different  parts  of  the  fauces.  Sometimes  the  disease  gradually  com- 
mences with  slight  ulcerations  on  the  tongue,  and  this  general  scalding 
of  the  tongue  and  fauces  follows.  The  bowels  are  usually  constipated, 
or  soon  become  so ;  no  fever,  but  at  times  excessive  irritation  of  the 
whole  system,  in  consequence,  probably,  of  the  want  of  rest ;  as  the 
continued  pain  of  the  fauces,  and  the  excessive  and  constant  flow  of 
burning  saliva  prevent  any  comfortable  rest  day  or  night.  The  tongue 
is  generally  free  from  any  coat,  or  it  may  have  a  light,  white  one. 
Occasionally,  although  the  surface  of  the  ulcerations  is  not  deep,  yet 
they  continue  to  increase  in  width,  and  the  inflammation  spreads  all 
over  the  mouth.  When  it  extends  from  the  mouth  and  fauces  to  the 
bowels,  diarrhea  ensues,  and  usually,  in  such  cases,  the  soreness  of  the 
mouth  becomes  better,  but  the  case  is  attended  with  more  danger. 
When  the  disease  is  severe  there  will  be  an  anaemic  condition  of  the 
system,  with  considerable  prostration  of  the  vital  energies. 

TREATMENT.— In  the  first  two  cases  of  this  disease  which  I 
attended,  having  never  seen  a  description  of  the  disease  in  any  medical 
work,  I  pursued  the  usual  treatment  for  aphthous  ulcerations,  and  lost 


SORE    MOUTH    OF    NURSING    WOMEN.  711 

my  patients ;  since  which,  my  success  in  the  treatment  of  it  has  been 
such  as  to  justify  me  in  recommending  the  following  plan: 

In  the  severe  or  obstinate  cases,  an  emetic  frequently  answers  a 
good  purpose,  and,  if  the  patient  is  not  too  weak,  should  be  given. 
The  emetic  I  usually  prefer  is  the  compound  powder  of  Lobelia.  In 
the  milder  cases  emetics  may  generally  be  dispensed  with. 

The  constipation  may  be  overcome  by  the  administration  of  such 
mild  means  as  will  prove  efficient  and  not  exhaust  the  patient.  Jalap 
acts  very  well  in  some  cases;  or,  where  the  tongue  shows  the  heavy 
yellow  coat  at  base,  Podophyllin  should  be  preferred. 

Internally,  the  tincture  of  Chloride  of  Iron  may  be  given,  in  doses 
of  twenty  drops,  and  should  be  repeated  every  two  or  three  hours. 
Formerly  I  was  in  the  habit  of  administering  alteratives,  as  the  com- 
pound syrup  of  Sarsaparilla,  compound  syrup  of  Yellow  Dock  root, 
or  the  compound  syrup  of  Stillingia,  with  a  proper  proportion  of  Iodide 
of  Potassium  added  to  the  syrup  used;  but,  though  these  will  be  fre- 
quently found  useful,  I  think  the  tincture  of  Iron  above  advised  will 
be  found  more  generally  successful,  from  its  direct  influence  on  the 
capillary  vessels,  and  the  beneficial  action  of  the  Iron  in  anaemia.  A 
saturated  solution  of  Chlorate  of  Potassa,  in  doses  of  a  fluiddrachm, 
repeated  every  three  or  four  hours,  has  frequently  proved  serviceable. 
And  in  some  instances  Bromide  of  Potassium,  or  of  Ammonium,  in 
conjunction  with  Sp.  Tr.  Iris  or  Nux  Vomica,  has  given  prompt 
relief. 

Sometimes  diarrhea  is  present,  in  which  case  no  purgative  must  be 
administered.  The  tincture  of  Chloride  of  Iron  in  doses  often  drops, 
diluted  sufficiently,  and  repeated  every  hour  or  two,  will  be  found  to 
have  a  most  excellent  influence  over  diarrhea,  especially  when  used 
in  conjunction  with  a  stimulating  and  astringent  injection,  such  as  a 
mixture  of  Tannic  Acid,  one  drachm,  Glycerine,  Elm  mucilage,  of 
each  half  a  fluid  ounce.  Mix  for  an  injection,  to  be  repeated  imme- 
diately after  each  stool.  Benefit  may  also  be  derived,  in  diarrhea,  by 
the  use  of  Liquor  Bismuth,  in  teaspoonful  doses,  two  or  three  times  a 
day.  Rice-water,  Elm-water,  infusion  of  Epilobium,  Blackberry 
root,  or  of  other  vegetable  astringents,  may  be  drank  freely. 

In  nearly  all  instances  of  this  disease,  a  deficient  action  of  the 
cutaneous  vessels  will  be  met  with,  and  which  it  is  absolutely  neces- 
sary to  remedy.  If,  as  is  sometimes  the  case,  the  disease  comes  on 
previous  to  parturition,  or  immediately  succeeding  delivery,  the  whole 
body  and  limbs  should  be  bathed  daily  with  a  weak  alkaline  wash,  to 
be  followed,  after  drying,  with  some  stimulating  application,  as  whisky 


712  KING'S  KOLECTIC  OBSTETRICS. 

and  water,  etc.  And  as  soon  after  delivery  as  may  be  prudent,  the 
spirit  vapor  bath  should  be  administered  twice  a  week,  or  accord- 
ing to  the  strength  of  the  patient.  Attention  to  the  surface  is  an 
exceedingly  important  part  of  the  treatment. 

The  aphthous  condition  of  the  mouth  and  fauces  must  also  be 
attended  to  locally.  A  solution  of  Nitrate  of  Silver,  from  sixty  to 
eighty  grains  of  the  salt  to  a  fluidounce  of  water,  will  generally  be 
found  useful  in  allaying  the  more  severe  scalding  and  painful  sensa- 
tions; the  whole  internal  surface  of  the  mouth  should  be  washed  with 
it  once  every  day,  or  every  other  day,  and  it  will  be  best  to  apply  it 
at  bedtime,  that  the  female  may  obtain  some  sleep  afterward.  Solu- 
tion of  Perchloride  of  Iron,  properly  diluted,  and  applied  one,  two, 
or  three  times  a  day  to  the  aphtha,  is  likewise  serviceable  in  many 
cases;  the  same  may  be  said  of  a  weak  solution  of  Sulphate  of 
Copper.  During  the  day,  the  mouth  and  throat  must  be  frequently 
washed  or  gargled  with  a  solution  of  one  of  the  following  preparations, 
a  small  portion  of  either  of  which  may  be  occasionally  swallowed 
with  benefit :  Fluid  Hydrastis,  Borax,  Chlorate  of  Potassa,  Phyto- 
lacca  or  Baptisia.  Undoubtedly  other  astringents,  an:l  agents  which 
influence  mucous  tissues,  will  be  of  value.  Solution  of  tincture  of 
Chloride  of  Iron,  or  of  diluted  Carbolate  of  Iodine,*  sprayed  upon 
the  aifected  parts,  have  each  been  found  of  efficacy. 

From  a  belief  that  this  malady  is  due  to  a  lack  of  phosphatic  salts 
in  the  blood — these  salts  not  having  been  assimilated  sufficiently  rapid 
to  supply  the  necessary  materials  for  the  growth  and  nutrition  of  the 
pregnant  woman  and  her  child — Dr.  N.  S.  Davis  has  advised  the  in- 
ternal use  of  the  compound  syrup  of  the  Hypophosphites,  in  doses  of 
one  or  two  fluidrachms,  three  or  four  times  a  day,  commencing  its 
use  as  soon  as  the  disease  manifests  itself,  and  continuing  it  during 
the  entire  period  of  lactation.  If  anemia  exist,  the  Pyrophosphate 
of  Iron  may  likewise  be  used  in  addition. 

The  diet  should  be  light  and  easy  of  digestion,  avoiding  fats,  stimula- 
ting liquors  (though  wine  is  indicated  when  there  is  a  great  prostration), 
gross  diet,  and  everything  which  will  cause  acidity  of  the  stomach,  or 
in  any  way  retard  or  derange  the  digestive  functions. 

*Tlie  diluted  Carbolate  of  Iodine  to  be  prepared  as  follows:  Take  of  Iodide  of 
Potassium,  ten  to  twenty-five  grains;  Iodine,  five  grains;  crystallized  Carbolic  acid, 
five  grains;  Glycerin,  clear,  soft  Water,  each,  nine  to  twenty-seven  fluidraclims  ;  mix 
and  dissolve  the  solids. 


SORE   MOUTH    OF    NURSING    WOMEN.  713 

It  is  always  advisable  to  cure  this  affection,  if  possible,  without 
weaning  the  child,  as  the  female  is  thereby  rendered  less  liable  to  its 
recurrence  at  another  parturient  period.  But,  if  the  soreness  and  pain 
are  excessively  intense,  a-nd  appear  to  be  intractable  to  all  treatment, 
and  more  especially  when  diarrhea  is  present,  weaning  may  become 
absolutely  necessary,  in  order  to  save  the  patient's  life.  In  these  cases, 
and  also  where  a  strong  disposition  exists  to  a  return  of  the  disease  at 
each  accouchement,  it  may  be  entirely  cured,  checked,  or  its  severity 
very  much  ameliorated,  by  regulating  the  bowels  during  pregnancy 
with  the  compound  powder  of  Rhubarb,  and  preserving,  as  much  as 
possible,  a  normal  condition  of  the  system,  by  some  alterative,  treat- 
ment persistently  used  during  the  whole  period  of  gestation.  Prof. 
Scudder  states  that  he  has  found  tobacco  smoking  to  be  of  more 
efficacy  in  this  affection,  than  any  other  local  application,  and  he  pre- 
fers it  to  all  mouth  washes. 


CHAPTER    LI  I. 

CYANOSIS RETENTION    OF    URINE — RED     GUM — JAUNDICE INFAN- 
TILE     OPHTHALMIA FLATULENT      COLIC CONSTIPATION  - 

UMBILICAL     HERNIA  —  EXCORIATION     OF     THE     NAVEL  — 
HEMORRHAGE       FROM       THE       CORD     -  HEMORRHAGE 
FROM    THE    NAVEL — NvEVUS  MATERNI — TONGUE- 
TIED HYDROCELE SWELLING    OF   THE 

BREASTS  —  HARE-LIP. 

As  soon  as  the  child  is  born,  and  breathes,  a  change  is  effected  in 
its  circulation ;  the  blood  which  had  partly  circulated  from  the  right 
into  the  left  auricle,  through  the  foramen  ovale,  during  intra-uterine 
existence,  as  well  as  that  which  had  flowed  through  the  ductus 
arteriosus,  from  the  pulmonary  artery  into  the  aorta,  now  changes  its 
direction  and  flows  toward  the  lungs,  through  the  pulmonary  artery. 
However,  cases  are  occasionally  met  with,  in  which  no  change  of  this 
kind  is  effected,  and  the  blood  continues  to  pass  from  the  right  to  the 
left  side  of  the  heart.  From  this  circumstance,  the  blood  is  imper- 
fectly oxygenized,  as  manifested  by  the  livid  or  blue  color  of  the  lips 
and  other  parts  of  the  body  which  are  protected  by  only  a  thin 
cuticle.  This  condition  is  termed  Blue  Disease,  Morbus  Cceruleus,  and 
Cyanosis. 


71 -i  KING'S  ECLECTIC  OBSTETRICS. 

The  two  auricles  of  the  heart  form  nearly  a  single  cavity,  at  the 
fifth  month  of  pregnancy,  in  consequence  of  the  imperfect  develop- 
ment of  the  septum  auricularum ;  but  this  septum  gradually  matures 
until  at  full  term  the  foramen  ovale  is  generally  considered  to  he  nearly 
or  quite  occluded. 

Cyanosis  may  be  occasioned  by  a  patulous  condition  of  the  foramen 
ovale,  or  by  some  malformation,  as,  deficient  ventricular  septum,  con- 
stricted pulmonary  artery,  or  any  other  abnormal  conditions  of  the 
heart  or  its  blood-vessels;  frequently,  the  foramen  ovale  may  continue 
open  after  birth,  or  may  re-open;  and,  anything  which  interferes  with 
the  return  of  the  blood  to  the  heart,  preventing  the  formation  of 
arterial  blood,  ma:  give  rise  to  the  blue  color  observed  in  this 
disease. 

The  symptoms  of  cyanosis  are  a  violet,  blue,  or  purple  color  of  the 
surface  of  the  body,  especially  the  face,  lips,  hands,  feet,  and  genitals, 
and  which  color  becomes  increased  by  exertion  or  excitement.  In 
addition  to  this,  indications  of  cardiac  disease  are  present,  in  a  greater 
or  less  degree,  as,  paroxysms  of  dyspnoea  of  long  or  short  duration, 
palpitation,  and  sometimes  syncope,  diminished  temperature  of  the 
surface,  and  an  extreme  susceptibility  to  the  influence  of  cold,  with  a 
strong  disposition  to  serous  eifusion.  The  child  is  most  commonly 
dull  and  sleepy,  its  respiration  being  slow,  and  frequently  labored,  and 
eventually  spasms  and  convulsions  occur  previous  to  the  fatal  termina- 
tion. However,  it  must  be  borne  in  mind,  that  oxygenation  of  the 
blood  is  less  important  to  an  infant  than  to  an  adult,  and  infants  have, 
at  times,  presented  symptoms  of  imperfect  oxygenation  of  the  blood, 
without  any  detrimental  results. 

Post-mortem  examinations  have,  in  the  majority  of  deaths  by 
cyanosis,  discovered  some  malformation  of  the'  heart,  its  blood-vessels, 
or  of  both.  Meckel  states,  that  "even  when  the  foramen  ovale  has 
remained  open,  there  may  be  no  cyanosis,  if  the  pulmonary  artery  is 
properly  formed." 

TREATMENT. — Although  cures  have  been  effected  in  this  disease, 
yet  we  are  not  to  anticipate  such  results  as  a  general  rule,  and  especially 
if  the  infant  be  attacked  with  spasms  or  convulsions. 

It  is  always  proper  to  attend  to  the  position  of  the  child,  as  recom- 
mended by  Professor  Meigs,  which  is,  to  place  it  on  its  right  side,  with 
the  body  inclined  at  an  angle  of  30°,  the  head  being  the  highest  part. 
On  a  moment's  reflection  it  will  be  seen  that  the  anatomical,  as  well 
as  the  mechanical  relations  of  the  parts,  indicate  this  position,  which 
maintains  the  left  auricle  perpendiculary  above  the  right,  and  the 


CYANOSIS.  715 

blood  must  thereby  gradually  pass  into  the  pulmonary  ventricle,  from 
the  force  of  gravity  alone.  Yet,  in  cases  depending  upon  malformation, 
no  benefit  could  result  from  this  or  any  other  position. 

In  connection  with  this  position,  the  child  must  not  be  allowed  to 
cry  or  worry,  but  should  be  kept  as  still  as  possible,  and  its  body 
should  be  occasionally  bathed  with  tepid  water  Should  tli^  natural 
color  of  the  skin  return  after  several  hours,  with  a  freer  respiration 
and  a  cessation  of  spasmodic  action,  all  that  will  be  necessary  in  the 
way  of  medicine,  is  a  gentle  purgative,  or  two. 

In  many  cases  the  disease  terminates  fatally  in  a  few  days,  and, 
sometimes,  not  until  after  several  months ;  the  affected  individual 
seldom  reaches  the  period  of  maturity.  Whenever  the  disease  does 
not  destroy  the  patient  after  a  few  weeks,  there  may  possibly  be  some 
benefit  derived  by  treating  him  for  a  chronic  disease  of  the  heart. 

Sometimes,  an  infant  will  pass  many  hours  after  its  birth  with  a 
RETENTION  OF  URINE.  This  may  be  owing  to  the  fact  that 
none  has  been  secreted ;  to  an  obstruction  or  debility  of  the  parts 
concerned  in  ejecting  the  urine;  or,  to  some  malformation,  or  closure 
of  the  urethra.  The  first  cause  may  be  overcome  by  the  use  of  such  mild 
diuretics  as  infusion  of  Pumpkin  seed  or  Watermelon  seed,  or  by  the 
administration  of  minute  doses  of  Acetate  of  Potassa,  Santonine  or 
Sp.  Tr.  Apis  Mel. ;  the  second,  by  placing  the  child  for  a  short  time 
in  a  warm  bath,  and  then,  after  drying  it,  applying  hot  fomentations 
over  the.  region  of  the  bladder.  The  third  cause  will  require  a  sur- 
gical operation  for  its  removal,  according  to  the  character  of  the 
difficulty. 

A  few  days  after  birth,  infants  are  attacked  with  a  cutaneous 
affection,  called  RED  GUM  (strophulus  intertinctus).  It  is  a  slight 
eruption  of  red,  or  sometimes  whitish  pimples,  which  are  surrounded 
by  a  reddish  halo.  This  is  probably  occasioned  by  the  exposure  of 
the  surface  to  the  action  of  the  atmosphere,  and  other  external  stimu- 
lating influences,  as  well  as  to  changes  effected  in  the  capillary 
circulation  by  the  increased  oxygenation  of  the  blood.  It  is  of  no 
importance  and  requires  no  especial  treatment.  The  skin  should  be 
frequently  powdered  with  Arrowroot,  and  if  there  be  any  derangement 
of  the  digestive  functions,  it  may  be  remedied  by  an  occasional 
dose  of  Lime-water,  or  if  the  child  is  nursed  from  a  bottle  a  small 
portion  of  it  may  be  added  to  the  milk.'  Nurses  are  frequently 


716  KING'S  ECLECTIC  OBSTETRICS. 

in  the  habit  of  giving  an  infusion  of  Catnip  and  Saffron  for  this  affec- 
tion, and,  as  no  harm  can  be  effected  by  it,  prohibition  would  not 
always  be  prudent. 

Infants  are  likewise  liable  to  a  yellowness  of  the  eyes  and  skin, 
shortly  after  birth,  termed  JAUNDICE;  and  with  this,  the  urine 
may  also  be  so  colored  with  bile  as  to  leave  yellow  stains  upon  the 
diapers.  Ordinarily,  this  is  of  but  little  consequence,  and  is  generally 
treated  by  an  infusion  of  Saffron  and  Catnip.  But  when  the  stools 
denote  biliary  derangement,  being  whitish,  clay-colored,  or  whitish 
yellow,  it  may  be  overcome  by  the  use  of  the  small  dose  of  Chion- 
anthus;  or  possibly  a  constipated  condition  of  the  mother,  in  such 
cases,  when  relieved  will  overcome  the  trouble  in  the  nursing  child. 
The  surface  should  be  kept  clean  by  daily  bathing.  Sometimes,  how- 
ever, in  consequence  of  malformation,  or  disease  of  the  liver  or  its 
ducts,  a  true  jaundice  may  exist,  and  which  is  apt  to  be  of  a  serious 
nature ;  but  this  is  not  of  very  frequent  occurrence. 

Shortly  after  birth,  say  on  the  second  or  third  day,  and  sometimes 
later,  infants  are  frequently  attacked  with  OPHTHALMIA  (ophthal- 
mia purulenta  infantum,  or  oph.  neonatorum) .  It  commences  with  a 
redness  and  swelling  of  the  lids,  and,  on  awaking,  the  lids  will  be 
observed  to  slightly  stick  together.  Light  occasions  pains,  and  con- 
sequently the  child  keeps»  its  eyes  closed.  At  first,  a  little  whitish 
matter  will  be  observed  lying  on  the  inside  of  the  lower  lid,  and  sub- 
sequently a  profuse  and  constant  discharge  of  thick,  yellow  matter 
takes  place,  and  which  covers  the  whole  eye.  If  this  be  allowed  to 
continue  without  attention,  the  child  may  ultimately  lose  its  eye.  The 
treatment  will  consist  in  cleanliness  and  agents  to  lessen  inflammatory 
action,  and  a  frequent  bathing  of  the  eye  with  water,  as  hot  as  can  be 
borne,  in  which  a  few  drops  of  Fluid  Hydrastis  may  be  used.  If  a 
more  stimulating  application  is  required,  eight  or  ten  grains  of  the 
Sesquicarbonate  of  Potassa  may  be  added  to  a  fluid  ounce  of  warm 
Water.  The  bowels  should  be  kept  regular.  Other  local  applications 
may  also  be  used  with  benefit,  as  a  mild  solution  of  Borax  with  Mor- 
phia, or  a  weak  solution  of  Sulphate  of  Zinc. 

INNUTRITION. — It  is  sometimes  the  case  that  a  rich,  creamy 
milk,  supplied  in  abundance  by  a  healthy  mother  or  nurse,  does  not 
afford  nutrition  to  the  child,  nor  appease  its  appetite,  but,  on  the  con- 


FLATULENT    COLIC.  717 

trary,  the  child  is  ravenous,  rapidly  emaciates,  has  the  look  of  an  old 
person,  and  suffers  from  diarrhea,  diuresis,  or  diaphoresis.  "Whenever 
a  case  of  this  kind  is  presented,  the  freshly  drawn  milk  from  the 
mother's  breast  should  be  carefully  examined.  It  will,  in  the  present 
instance,  be  found  to  vary  in  color,  be  neutral  or  alkaline,  rich  in 
saccharine  matter,  of  specific  gravity  1024  to  1035,  and  under  the 
microscope  will  be  found  to  contain  animalcules,  vibriones,  and  monads 
(vibrio  lactis ;  monas  lactis).  These  animalcules  are  attributed  to 
fermentation  of  the  saccharine  element  of  the  milk  while  yet  within 
the  mammary  glands ;  the  fermentation  being  probably  due  to  sexual 
excitement,  together  with,  perhaps,  more  or  less  congested  condition 
of  the  glands.  In  these  cases  the  child  should  be  immediately  with- 
drawn from  further  use  of  such  milk,  and  be  fed  by  the  bottle,  using 
the  milk  from  one  cow,  which  may  be  properly  diluted  with  Lime- 
water;  or  one  of  the  prepared  foods  may  be  substituted,  among  which 
I  prefer  the  Malted  Milk. 

Infants  are  frequently  troubled  with  FLATULENT  COLIC,  which 
may  arise  from  costiveness,  exposure  to  cold,  from  being  allowed  to 
suckle  too  much,  from  irregularities  in  the  diet  of  the  nurse,  or  some 
bad  quality  of  her  milk.  It  usually  comes  on  suddenly,  and  may  be 
known  by  the  violent  and  incessant  screaming  of  the  child,  the  hard- 
ness of  the  abdominal  muscles,  and  the  constant  agitation  of  the  limbs, 
which  are  extended  to  their  utmost,  and  then  immediately  drawn  up 
toward  the  abdomen,  in  rapid  succession. 

The  TREATMENT  consists  in  giving  a  laxative  and  carminative 
injection,  after  which  a  warm  infusion  of  Peppermint  (or  Spearmint, 
should  a  suppression  of  urine  be  present),  sweetened,  and  to  which  a 
very  small  quantity  of  Supercarbonate  of  Soda  has  been  added,  should 
be  given,  as  an  increased  acidity  of  the  stomach  is  apt  to  be 
present ;  or,  the  syrup  of  Rheum  Aromatica  may  be  substituted, 
when  further  action  on  the  bowels  is  desired.  When  the  attack  is 
very  severe,  the  bowels  and  back  of  the  child  should  be  covered  with 
flannels  or  fomentations,  made  as  hot  as  can  be  borne,  and  the  child 
being  held  with  its  abdomen  on  the  nurse's  knee,  should  be  trotted  for 
some  time,  while  she  gives  a  succession  of  light  taps  with  her  hand  on 
its  back,  between  the  shoulder-blades  and  down  to  the  small  of  its 
back.  By  this  means,  I  have  frequently  removed  the  most  severe 
cases  of  colic,  where  the  child  had  been  screaming  incessantly  for 
hours,  and  had  taken  Paregoric,  Godfrey's  Cordial,  hot  Gin  Sling,  etc., 
without  the  least  benefit. 


718  KING'S   KCI.KCTIC  <>I',STKTUICS. 

CONSTIPATION,  is  common  to  some  infants,  and  often 
obstinate,  being  rather  perpetuated  by  the  administration  of  purga- 
tives. The  introduction  of  a  suppository  of  soap  is,  generally,  the  best 
agent  that  can  be  used  in  order  to  procure  a  stool ;  two  evacuations 
should  be  obtained  daily,  at  regular  hours.  And  in  the  interim,  the 
following -should  be  injected  into  the  rectum,  three  or  four  times  daily, 
and  retained  within  as  long  as  possible,  by  means  of  a  compress,  if 
necessary:  Take  of  a  strong  infusion  of  Hydrastis  Canadensis,  two 
Huidrachms,  tincture  of  Prickly-ash  berries,  twenty  or  thirty  minims; 
mix  for  an  enema.  This  gives  tone  and  activity  to  the  parts  with 
•-vim-hit  comes  in  contact,  and  also  to  neighboring  parts  by  sympa- 
thetic action.  Tepid  water,  with  a  small  amount  of  Glycerine,  will 
also  answer  a  very  good  purpose  in  some  cases.  Internally,  agents, 
as  a  rule,  prove  irritating  to  the  intestines,  and  should  not  be  given. 
The  massage  treatment,  over  the  bowels,  will  increase  peristalsis  and 
frequently  be  all  that  is  necessary.  Tincture  of  Bryonia,  one  drop  in 
water,  repeated  two,  three,  or  four  times  a  day,  will  frequently  be 
found  very  efficacious. 

UMBILICAL  HERNIA,  may  occur  soon  after  birth,  or  at  a  later 
period.  It  may  be  occasioned  by  a  large  umbilicus,  or,  from  straining 
while  crying,  coughing,  etc.  It  should  always  be  attended  to  at  once. 
Place  the  child  on  its  back,  with  the  shoulders  slightly  elevated,  and 
the  thighs  flexed  toward  \he  abdomen.  Then  carefully  push  the  pro- 
truding tumor  back,  apply  a  compress  over  it,  and  maintain  it  in  place 
by  a  bandage.  In  some  instances,  an  umbilicus  truss  may  be  required, 
several  kinds  of  which  are  in  use,  but  I  prefer  those  manufactured  by 
Max  Wocher  &  Son,  or  by  Mr.  W.  Autenreith,  of  this  city,  surgical 
instrument  makers,  who  manufacture  very  available  trusses  for  this 
and  other  forms  of  hernia.  The  compress,  above  advised,  may  be 
made  of  linen,  folded  several  times,  and  moistened  with  some 
astringent;  or,  a  piece  of  cork,  may  be  cut  of  the  proper  size  and 
shape,  covered  with  linen  or  soft  leather,  and  applied.  Adhesive 
inflammation,  sufficient  to  unite  the  parts,  will  take  place  in  four  or 
five  days,  though  the  treatment  should  be  continued  for  twelve  or 
fourteen  days;  and  after  this  period  has  passed,  the  abdomen  should 
be  properly  supported  by  a  bandage,  for,  several  months,  in  order  to 
prevent  a  return  of  the  rupture ;  and  constipation  should  carefully  be 
guarded  against  by  proper  laxatives,  etc. 


EXCORIATION    OF    THE    NAVEL — XJEVUS    MATERXI.  719 

EXCORIATION  OF  THE  NAVEL  may  be  successfully  treated 
by  washing  the  part  twice  a  day  with  some  Castile  soapsuds,  and  then 
dressing  it  with  the  Red  Oxide  of  Lead  plaster,  or  the  compound 
Lead  ointment ;  or  frequently  a  few  applications  of  Tannate  of  Glycer- 
ine will  be  all  that  is  needed.  If  there  is  a  tendency  to  gangrene, 
Sulphate  of  Zinc,  either  in  powder  or  solution,  may  be  applied, 
together  with  emollient  poultices;  and  the  strength  of  the  system 
should  be  kept  up  by  tonics. 

Sometimes,  from  a  shrinking  of  the  umbilical  cord,  or  from  its 
being  carelessly  tied,  the  ligature  will  not  press  sufficiently  on  its 
blood-vessels,  and  a  HEMORRHAGE  will  take  place.  In  such  cases, 
a  second  ligature  must  be  applied  below  the  original  one,  and  which 
should  make  the  proper  compression  upon  the  vessels  without  cutting 
the  cord. 

Occasionally,  at  the  time  of  the  separation  of  the  cord  from  the 
navel,  or  a  day  or  two  subsequently,  HEMORRHAGE  FROM 
THE  UMBILICUS,  will  ensue,  being  frequently  accompanied  with 
fungus  growths.  This  difficulty  may  be  overcome  by  the  application 
of  Sulphate  of  Zinc,  either  in  powder  or  in  solution  followed  by  the 
red  oxide  of  Lead  plaster,  or,  compound  Lead  ointment ;  and,  if 
much  inflammation  be  present,  emollient  poultices  should  be 
applied. 

N JE VUS  M ATERNI,  or  mother's  marks,  -are  frequently  met  with  ; 
they  may  exist  on  any  part  of  the  body,  and  present  various  appear- 
ances, some  being  better  supplied  with  blood  than  others.  When  they 
are  superficial,  manifesting  no  tendency  to  spread,  no  treatment  is 
required,  except  to  remove  the  disfiguration  from  the  face.  When 
they  are  of  the  character  of  "  aneurism  by  anastomosis,"  having  a 
tendency  to  spread  or  enlarge,  to  ulcerate,  or  to  bleed  profusely,  it  is 
advisable  to  remove  them  when  possible. 

Various  modes  of  TREATMENT  have  been  recommended  for  the 
removal  of  these  marks,  to  which  I  will  merely  make  a  brief  reference ; 
as,  destruction  of  them  by  the  application  of  platinum  wire,  heated  by 
galvanism ;  the  injection  of  a  small  quantity  of  the  solution  of 
Perchloride  of  Iron  into  various  parts  of  the  naevus;  the  application 
of  the  ligature  to  some  varieties;  the  application  of  intense  cold  over 
the  part;  and,  in  the  subcutaneous  form,  it  has  been  removed  by 
vaccinating  .in  the  mark.  The  application  of  powdered  Sulphate  of 
Zinc  over  the  nsevus,  repeated  daily,  and  continued  until  it  is  destroyed, 
then  facilitating  the  removal  of  the  slough  by  an  Elm  poultice,  and 


720  KING'S  ECLECTIC  OBSTETRICS. 

subsequently  treating  the  ulcer  with  the  compound  Lead  ointment,  has 
succeeded  in  several  instances  in  effecting  a  cure,  even  in  cases,  where 
the  nsevus  assumed  a  malignant  appearance.  If  not  removed  after  the 
slough  has  passed  off,  renew  the  application  of  the  Zinc,  and  follow  by 
the  same  treatment  as  above. 

Infants  are  occasionally  troubled  with  a  condition,  known  as  being 
TONGUE-TIED.  This  arises  from  the  frsenum  linguae,  or  bridle 
under  the  tongue,  being  so  short,  or  attached  so  far  forward  as  to 
interfere  with  the  motions  of  the  tongue  in  sucking,  as  well  as  in 
speaking,  when  further  advanced  in  years;  occasionally,  it  is  owing  to 
the  presence  of  a  false  membrane.  If  the  infant  can  protrude  the 
tip  of  the  tongue  beyond  the  lips,  or  can  suck  well,  no  interference  is 
demanded,  for  there  is  no  difficulty  of  the  kind.  It  is  of  very  rare 
occurrence. 

The  TREATMENT  consists  in  cutting  the  frsenum,  so  as  to  loosen 
the  tongue  from  its  attachment.  The  best  time  for  operating  is  when 
the  infant  sleeps ;  the  tongue  may  then  be  held  up  with  the  index  or 
forefinger  of  one  hand,  while  with  the  other,  holding  a  pair  of  blunt 
scissors,  and  having  its  points  directed  downward  and  as  near  the  floor 
of  the  mouth  as  possible,  cut  loose  about  one-eighth  of  an  inch  of  the 
anterior  .portion  of  the  membrane — and  which  will  be  followed  by 
only  a  few  drops  of  blood  which  must  be  wiped  out.  Care  must  be 
taken  not  to  cut  the  lingual  artery,  which  is  situated  on  the  inferior 
surface  of  the  tongue ;  and,  should  it  be  imprudently  cut,  the 
hemorrhage  must  be  checked  by  compression,  or  the  actual  cautery. 
If  too  extensive  a  cut  be  made,  the  child  may  swallow  its  tongue, 
which,  however,  may  be  returned,  by  passing  a  spoon  dipped  in 
molasses  or  syrup  down  to  the  point  or  edges  of  the  organ,  and 
bringing  it  back. 

HYDROCELE,  is  sometimes  met  with  in  infants,  and  is  generally 
removed  by  the  application  of  compresses  moistened  with  a  solution 
of  Muriate  of  Ammonia.  It  is  rare  that  a  puncture  will  be  required. 

Infants,  soon  after  birth,  are  sometimes  troubled  with  a  SWELLING 
AND  HARDNESS  OF  THE  BREASTS,  which  may  be  owing  to 
cold,  blows,  bruises,  or,  an  excited  condition  of  the  parts.  It  may  be 
overcome  by  gentle  frictions  with  Olive  Oil  and  tincture  of  Camphor 
applied  two  or  three  times  a  day,  employing  in  the  intervals  fomenta- 


HARE-LIP.  721 

tions  of  Mullen  leaves  and  blossoms,  or  a  weak  solution  of 
Arnica;  if  there  is  much  inflammation,  poultice  of  Elm  and  Lobelia 
may  be  applied.  Occasionally,  and  especially  if  neglected,  or 
improperly  treated,  sloughing  will  take  place ;  this  may  be  treated  by 
stimulating  \vashes,  and  the  red  oxide  of  Lead  plaster,  in  conjunction 
with  tonics  internally,  when  there  is  much  debility. 

HARE-LIP,  is  an  imperfection  often  met  with  after  birth.  It  is  a 
perpendicular  or  oblique  division  of  the  upper  lip,  either  immediately 
under  the  septum  of  the  nose,  or  under  one  of  the  nostrils.  Double 
hare-lip  is  when  there  are  two  divisions.  Sometimes  the  fissure 
extends  back  through  the  palate  bone,  as  well  as  through  the  soft 
palate,  in  which  case,  an  operation  has  sometimes  been  performed, 
which  may  be  found  described  in  surgical  works. 

In  ordinary  cases  of  hare-lip  the  deformity  is  removed  by  a  simple 
operation ;  and,  011  account  of  the  tendency  to  convulsions  in  very 
young  children,  after  the  operation,  it  is  better  to  wait  until  they  are 
at  least  two  or  three  weeks  old;  a  year  or  two  is  still  better,  if  the 
child  can  suck,  or  be  safely  fed  in  the  meantime. 

The  operation  is  performed,  by  removing  the  edges  of  the  fissure 
with  a  pair  of  long-handled,  sharp  scissors,  made  for  the  purpose. 
Should  the  gum  and  lip  be  adherent,  they  must  be  separated  by  the 
knife;  and  when  the  frsenulum  is  in  the  way  of  the  operation,  it 
must  be  divided.  The  incision,  by  whatever  instrument  it  is  effected, 
should  be  as  smooth  and  even  as  possible,  that  the  edges  may  readily 
unite  by  the  first  intention. 

The  fissure,  now  resembling  the  inverted  letter  A,  is  to  be  closed, 
bringing  the  edges  together  by  means  of  silver  wire.  The  first  suture 
should  be  introduced  through  and  across  the  wound  at  its  inferior 
lower  termination ;  it  should  penetrate  sufficiently  deep,  say  about  two- 
thirds  through  the  substance  of  the  lip,  to  keep  the  cut  surfaces  in 
approximation,  but  should  not  pass  through  the  inner  surface  of  the 
lip.  One  or  two  other  sutures  are  then  to  be  passed  similarly,  at 
equidistant  points  from  the  first,  being  thrust,  as  before,  sufficiently 
deep  to  almost  reach  the  inner  mucous  lining  of  the  lip.  The  wire  is 
to  be  twisted  sufficiently  to  keep  the  outer  surface  of  the  wound  in 
close  contact,  being  careful,  however,  not  to  apply  them  so  tightly  as 
to  occasion  a  subsequent  sloughing  of  the  parts.  Should  high  inflam- 
matory action  supervene,  it  may  be  reduced  by  the  application  of 
cold  water;  and  any  tendency  to  cerebral  irritation,  or  sympathetic 
fever,  should  be  at  once  removed  by  appropriate  means. 
46 


722  KING'S  ECLECTIC  OBSTETRICS. 

The  child  should  be  kept  in  a  room,  away  from  any  excitement 
which  would  occasion  crying  or  laughing,  aiid  even  talking,  when  old 
enough,  and  must  be  fed  with  a  spoon,  the  diet  being  entirely  of  a 
fluid  character.  And  should  there  be  any  danger  of  a  disarrangement 
of  the  parts,  the  cheeks  may  be  pressed  forward,  and  then  a  long  strip 
of  adhesive  plaster,  reaching  from  ear  to  ear,  may  be  applied  between 
these  points  and  over  the  lip. 

After  four,  five,  or  six  days,  the  sutures  may  be  removed,  and  strips 
of  adhesive  plaster  applied,  which  will  be  sufficient  to  hold  the  parts 
together.  In  removing  the  sutures,  loosen  them  gradually  with  the 
forceps,  as  any  sudden  jerks,  or  forcible  pulling,  would  be  apt  to 
separate,  or  otherwise  injure  the  wound.  If  there  be  a  double  hare-lip, 
it  will  be  better  to  complete  the  operation  by  incising  and  ligaturing 
both  fissures  at  the  same  time. 


CHAPTER    LIII. 

PAHTH^C,    THRUSH TKISMUS     NASCENTIUM PORRIGO     LARVA  US, 

MILK    SCAB. 

INFANTS  are  subject  to  an  inflammation  of  the  mouth,  called 
APHTHAE,  Thrush,  or  Stomatite  Folliculeuse,  the  symptoms  of  which 
vary  according  to  the  severity  of  the  attack.  Upon  an  examination, 
the  tongue,  lips,  and  interior  surface  of  the  mouth  and  throat,  will  be 
found  more  or  less  covered  with  small,  white  flakes,  or  pearl-colored 
vesicles,  which  proceed  to  superficial  ulceration,  and  terminate  by  an 
exfoliation  of  white  crusts.  These  vesicles  may  be  distinct,  or  con- 
fluent, and  in  the  more  severe  forms,  are  accompanied  with  so  much 
pain  that  the  child  can  not  suck,  its  mouth  is  hot,  its  lips  frequently 
swollen,  with  a  dribbling  of  saliva.  The  breath  is  usually  disagreea- 
ble and  of  an  acid  odor,  the  pulse  quick  and  feeble,  bowels  deranged, 
frequent  vomiting,  and  a  diarrhea  with  green  or  watery  evacuations, 
and  excoriated  anus.  The  disease  may  extend  to  the  pharynx,  and 
trachea,  and,  in  very  severe  cases,  it  is  continued  through  the  alimen- 
tary canal  to  the  anus.  The  child  becomes  pale,  restless,  and  fretful, 
rapidly  emaciating,  and  presenting  a  countenance  indicative  of  much 
distress.  When  mild,  but  few  of  these  symptoms  are  manifested  ;  but 
when  very  severe,  there  may  also  be  cephalic  disturbance,  severe 
abdominal  pain,  diarrhea,  and  typhoid  symptoms,  under  which  the 
little  patient  will  rapidly  sink.  Occasionally  the  ulcers  assume  a 
gangrenous  condition. 


APHTHJE.  723 

Weakly  and  unhealthy  children,  as  well  as  those  raised  by  hand,  are 
more  subject  to  this  disease  than  others;  it  may  also  be  induced  by 
improper  food,  uncleanliness,  unhealthy  air,  and  not  nn&equently 
occurs  as  a  secondary  affection  to  other  diseases. 

It  is  sometimes  mistaken  for  a  disease  occasionally  met  with,  called 
White  Thrush,  or  Muguet,  but  may  be  distinguished,  by  remembering 
that  this  latter  affection  presents  no  ulceratiou,  being  a  deposition  of 
curdy  matter  or  false  membrane  upon  the  epithelium,  without  involv- 
ing the  destruction  of  the  adjacent  membrane ;  while  in  true  Thrush, 
the  follicular  points  of  the  tongue  enlarge,  without  losing  their  circu- 
lar form,  and  from  their  central  orifices  a  whitish  matter  escapes, 
being  accompanied  by  ulceration.  The  ulcer  has  rounded  edges,  is 
more  or  less  tumefied,  and  is  invariably  surrounded  by  an  inflamed 
red  circle. 

In  the  mild  form,  the  white  crusts  fall  off,  and  in  a  few  days  the 
ulcers  heal.  But  when  the  aphthae  are  confluent,  with  extensive  ul- 
ceration, vomiting,  and  diarrhea,  or  when  the  crusts,  instead  of  being 
white,  are  of  a  dark  color,  with  an  unhealthy  appearance  of  the  ulcers, 
the  pulse  being  quick  and  feeble,  with  rapid  emaciation,  the  prognosis 
is  very  unfavorable. 

TREATMENT.— In  the  milder  forms  of  this  disease  little  or  no 
treatment  is  necessary,  but  in  the  severe  forms  it  is  indispensable. 
The  treatment  should  be  commenced  by  proper  attention  to  diet;  fre- 
quently, where  the  child  is  fed  from  a  bottle,  the  bottle  is  allowed  to 
become  sour  and  filthy,  and  proper  attention  to  cleanliness  will  over- 
come the  trouble,  or  the  addition  of  Lime-water  to  the  milk  answers 
well  in  other  cases;  it  may  become  necessary,  however,  to  change  to 
a  wet  nurse.  It  will  be  well  in  most  cases  to  obtain  the  effect  of 
some  mild  agent  to  move  the  bowels,  as  the  Aromatic  Syrup  of  Rhu- 
barb. After  and  during  the  action  of  the  laxative — which  should  be 
exhibited  daily,  at  least  for  a  few  days — two  or  three  drops  of  the 
tincture  of  Chloride  of  Iron  should  be  given  in  a  sufficient  quantity 
of  infusion  of  Hydrastis  Canadensis,  or  Fluid  Hydrastis,  and  this 
may  be  repeated  every  two,  three,  or  four  hours,  according  to  the 
severity  of  the  disease.  I  have  heretofore  made  a  brief  reference  to 
the  action  of  this  chalybeate,  so  that  it  will  be  unnecessary  here.  I 
have  gotten  very  good  results,  in  this  trouble,  from  the  use  of  Borax, 
either  in  powder  or  solution;  some  prefer  to  use  it  in  honey. 

Care  must  be  employed  not  to  irritate  the  mouth  by  rough  swab- 
bing, or  by  forcing  off  the  white  flakes  or  deadened  epithelium,  as 
either  of  these  may  augment  the  severity  of  the  disease.  There  are 


724  KING'S  ECLECTIC  OBSTETRICS. 

other  agents  which  may  be  used  with  advantage  as  local  applications, 
as  Hamamelis  Virginica,  a  solution  of  Alum,  or  Nitrate  of  Silver, 
etc.;  but  I  prefer  the  above,  which  I  have  employed  with  much  suc- 
cess in  a  number  of  cases,  always  administering  some  of  it  internally. 
Chlorate  of  Potassa  internally,  and  applied  locally,  in  solution,  has 
been  found  a  very  efficacious  remedy  in  most  cases.  I  have  used  it 
in  a  few  cases,  and  with  advantage.  Sulphite  of  Sodu  one  drachm, 
Distilled  Water  one  fluid  ounce,  Carbolic  Acid  two  or  three  grains, 
mixed  together,  and  applied  upon  the  aphtha?  by  means  of  a  camel's 
hair  pencil,  has  often  proved  highly  efficacious. 

When  vomiting  occurs,  Aconite  and  Ipecac,  or  Nux  Vomica,  in 
minute  doses,  may  be  used,  or,  in  some  cases,  Bismuth  may  answer  a 
better  purpose ;  and  if  the  irritation  has  extended  into  the  stomach 
or  alimentary  canal,  we  will  again  find  the  Aconite  and  Ipecac 
useful,  or  an  infusion  of  the  bark  of  the  twigs  of  Peach-tree  will 
often  act  well.  Perhaps  Cod-liver  Oil,  or  Cocoanut  Oil,  might 
be  useful  in  some  cases.  When  the  ulcers  assume  a  dark  or  brown 
hue,  or  exhibit  a  gangrenous  tendency,  equal  parts  of  Salad  Oil,  Yeast, 
and  Spirits  of  Nitric  Ether,  may  be  given  in  doses  suited  to  the 
child's  age,  and  which  should  be  repeated  at  proper  intervals.  Or 
some  of  the  agents  heretofore  named  for  such  condition  may  be  used, 
as,  the  Sulpho-carbolites,  Baptisia,  diluted  Nitric  acid,  Permanganate 
of  Potassa,  etc.  In  addition  to  this,  the  system  should  be  supported 
by  Quinia,  Iron,  and  cordials,  as  wine-whey,  milk  and  wine,  chicken- 
broth  and  wine,  etc.  Sometimes  the  Iodide  of  Potassium,  or,  Iodide 
of  Iron,  combined  with  some  alterative,  will  be  found  valuable, 
especially  with  children  of  scrofulous  parents. 

When  there  is  excoriation  of  the  anus,  it  should  be  frequently  and 
gently  bathed  with  warm  water,,  dried  carefully,  and  then  sprinkled 
with  Bismuth  or  finely  powdered  Elm  Bark,  or  dressed  with  Tannate 
of  Glycerine. 

The  body  of  the  child  should  be  kept  clean,  frequently  bathing  it 
with  warm  water,  or  a  weak  alkaline  solution;  and  if  it  be  much 
debilitated,  brandy  or  some  other  stimulant  may  be  added  to  the 
solution.  Attention  should  be  paid  to  the  condition  of  the  mother's 
health,  who  must  be  placed  under  treatment  if  necessary:  her  diet 
must  invariably  be  regulated,  as  well  as  the  condition  of  the  bowels, 
exercise,  etc.  It  not  unfrequently  occurs,  that  a  change  of  the  nurse, 
or  weaning  the  child  and  feeding  it  cow's  milk,  arrowroot,  barley- 
water,  etc.,  will  be  followed  by  a  disappearance  of  all  the  symptoms; 
shortly  after  which,  if  the  mother's  milk  has  not  been  allowed  to  "  dry 
up,"  it  may  be  safely  restored  to  its  natural  fc/od.  (See  Innutrition.) 


MILK     SCALL.  725 

Among  the  several  cutaneous  diseases  to  which  infants  are  liable,  is 
Due  known  as  milk  scad,  or  milk  scab,  and  which  has  been  variously 
termed  by  writers,  thus,  Porrigo  Larvalis,  Crusla  Lactea,  Pornyo  Favosa, 
Tinea  Lactea,  etc.  The  disease  is  usually  first  observed  upon  the  fore- 
head and  cheeks,  and  consists  in  an  eruption  of  minute  superficial 
pustules,  of  a  yellowish-white  color,  united  in  groups  on  a  red  surface, 
and  more  or  less  confluent.  It  sometimes  attacks  the  hands,  feet,  and 
other  parts  of  the  body,  and  has  likewise  been  observed  in  adults. 
The  pustules  will  at  first  be  found  to  contain  a  transparent  fluid, 
Avhich  soon  becomes  yellowish-white  and  opaque,  and  being  dis- 
charged, concretes  into  thin,  yellowish,  or  greenish  crusts.  As  the 
pustular  patches  spread,  there  is  a  renewal  of  the  discharge,  which 
likewise  continues  from  beneath  the  crusts,  increasing  their  thickness 
and  extent.  The  eruption  is  subject  to  various  modifications — some- 
times the  discharge  is  scarcely  perceptible,  with  a  dry  and  brown  scab 
covering  the  surface;  at  other  times,  the  discharge  is  profuse,  with  a 
red  and  excoriated  surface.  Occasionally,  the  whole  face,  with  the 
exception  of  the  nose  and  eyelids,  is  covered  like  a  mask,  with  a  large, 
thick  crust,  formed  of  numerous  smaller  ones,  and,  almost  invariably, 
the  disease  is  accompanied  with  intense  itching,  and  more  or  less  pain. 
When  the  disease  is  about  terminating,  the  discharge  gradually  ceases, 
the  crusts  fall  off  and  are  not  renewed,  the  surface  under  them,  at  first 
elevated,  red,  and  tender,  gradually  lessens  in  color,  slight  desquama- 
tion  ensues,  and  the  skin  slowly  returns  to  its  normal  condition  without 
any  disfiguration,  unless  the  child  has  been  allowed  to  tear  its  cheeks 
by  scratching. 

The  duration  of  the  disease  is  variable,  and  it  is  not  uncommon  for 
it  to  remain  several  months  before  disappearing.  It  rarely  remains 
beyond  the  period  of  teething,  and  hence,  in  obstinate  cases,  means 
should  be  employed  to  allay  the  itching,  that  the  face  may  not  be 
marked  by  the  nails  of  the  child.  It  does  not  appear  to  be  conta- 
gious; and  its  causes  are  involved  in  much  obscurity. 

TREATMENT. — Microscopic  investigations  are  stated  to  have 
discovered  that  the  disease  depends  upon  a  vegetable  parasitic  growth, 
and  may  be  cured  by  the  local  application  and  internal  administra- 
tion of  a  solution  of  Sulphite  of  Soda  in  some  bitter  tonic.  I  have 
recently  employed  this  solution  internally,  together  with  a  solution 
of  Perchloride  of  Iron  locally,  to  the  aphtha,  with  marked  benefit; 
in  some  instances,  solution  of  Chlorate  of  Potassa  may  be  substituted 
for  that  of  the  Ferruginous  Perchloride.  Carbolate  of  Iodine,  as  a 
local  application,  will  be  found  highly  advantageous  in  many  instances. 


72(5  KING'S  ECLECTIC  OBSTETRICS. 

If  there  is  any  derangement  of  the  digestive  or  hepatic  functions,, 
administer  laxative  doses,  every  day  or  two,  of  the  Aromatic  Syrup 
of  Rhubarb.  The  minute  dose  of  Chionauthus  answers  well  in  some 
cases;  in  others,  Sp.  Tr.  of  Iris  may  be  given;  and  again,  the  action 
of  Nux  Vomiea  or  Fowler's  Solution  is  desirable.  Good  effects  may 
likewise  be  derived  by  the  administration  of  Ilhus  Tox.  The  diet 
of  the  child  should  be  regulated  as  to  quantity,  and  the  periods  of 
feeding;  in  several  eases  the  disease  has  proved  unyielding  until  the 
child  was  given  to  another  nurse,  when  it  rapidly  disappeared. 

The  child  should  be  exercised  freely  by  its  attendant,  and  be 
exposed  as  much  as  possible  to  the  open  atmosphere,  in  pleasant 
weather. 

CORY  Z  A,  Nasal  Catarrh,  or  Snuffles,  is  a  very  common  and 
troublesome  disease  among  infants.  It  is  an  affection  of  the  nasal 
mucous  membrane  and  air  passages  of  the  head,  and  generally  com- 
mences by  frequent  sneezing;  at  first  there  is  little  discharge  from  the 
nostrils,  but  in  a  short  time,  a  thin  mucous  secretion  takes  place,, 
which  finally  becomes  profuse,  and  of  a  thick,  muco-puruient  character. 
Not  unfrequently,  the  discharge  is  acrid  and  irritating.  The  mucous 
fills  the  passages,  forming  a  very  troublesome  obstruction,  causing  the 
child  to  make  a  snuffling  or  rattling  sound  in  breathing  through  the 
nose,  and  interfering  with  its  free  respiration  while  sucking.  The 
eyes  are  more  or  less  suffused,  watery,  and  sensitive  to  light,  and  the 
thirst  is  increased,  with  some  slight  febrile  disturbance.  Sometimes, 
especially  when  the  disease  appears  epidemically,  the  symptoms  are 
much  more  severe,  with  great  constitutional  debility.  After  the  third 
or  fourth  day  the  symptoms  usually  diminish,  but,  and  especially  when 
not  under  treatment,  or  in  the  severe  forms,  it  may  continue  for  several 
weeks. 

Coryza  is  usually  produced  by  cold ;  at  times  it  prevails  as  an 
epidemic ;  and  it  is  frequently  found  accompanying  other  diseases,  as 
the  exanthemata.  Usually  the  disease  requires  but  little  treatment, 
but  in  its  severe  forms,  it  must  be  watched,  as  the  child  may  die 
from  the  obstruction  preventing  free  access  of  atmospheric  air  to  the 
lungs. 

TREATMENT.— In  mild  cases,  inunction  of  the  nostrils  will 
frequently  be  all  the  treatment  needed;  for  this  purpose  Vaseline 
answers,  or,  what  some  consider  still  better,  an  application  of  goose- 
grease  or  tallow  may  be  used.  This  greasing  of  the  nose  and  forehead 
externally  is  a  common  practice  with  nurses,  and  I  have  found  it 


CORYZA.  727 

decidedly  beneficial;  and,  notwithstanding  many  of  our  eminent 
practitioners  treat  with  disdain  the  simple  measures  advised  by  old 
nurses,  it  is  well  to  remember  that  they  are  more  observing  of,  and 
have  better  opportunities  to  ascertain,  the  influence  of  agents  upon 
children  than  physicians,  who  seldom  remain  with  a  patient  to  exceed 
fifteen  minutes  at  a  visit;  and  he  who  will  listen  to  and  watch  the 
opinions  and  methods  adopted  by  them,  especially  in  the  manage- 
ment of  infants,  can  never  fail  to  derive  some  useful  and  valuable 
suggestions. 

In  the  severe  forms  of  this  disease,  the  patient  is  put  upon  the  use 
of  the  sedative.  Aconite,  in  the  small  dose,  will  be  the  usual  remedy ; 
this  may  be  aided  in  its  action  by  the  hot  bath.  When  the  discharges 
become  acrid,  and  the  membranes  show  decided  irritation,  Rhus  Tox 
should  be  given  with  the  Aconite.  The  indication  for  Gelsemium  will 
frequently  be  present,  as  well  as  that  for  Belladonna.  Frequently  there 
will  be  an  enlargement  of  the  lymphatic  glands  about  the  neck ;  such 
a  condition  calls  for  Phytolacca.  Specific  medication  acts  very 
promptly  in  children's  diseases;  consequently,  the  symptoms  should 
be  carefully  noted,  and  the  indications  followed. 

When  the  nose  is  much  obstructed,  the  infant  should  be  taken  from 
the  breast  for  a  few  days,  and  be  fed  at  regular  intervals,  two  or  three 
times  a  day.  Children  two  or  three  years  of  age  should  be  kept  on  a 
low  diet  during  the  first  stage  of  the  disease.  The  surface  should  be 
bathed  with  warm  water  daily,  the  body  should  be  kept  properly 
warmed,  and  a  flannel  cap  should  be  worn,  not  only  during  the  disease, 
but  for  some  days  after  its  cure. 


INDEX. 


Abdomen,  enlargement  of 196 

laxity  of 240 

rigidity  of 240 

subsidence  of 273 

Abdominal  muscles,  relaxed 404 

Abdominal  palpation 203 

Abdominal  pregnancy 186 

Abnormally  large  pelvis 39 

Abortion 249 

causes  of 250  • 

diagnosis  of 253 

habitual 264 

hemorrhage  during 249,  258 

prognosis  of 254 

symptoms  of 252 

treatment  of 25G 

Abscess,  mammary 700 

Accidental  hemorrhage 502 

diagnosis  of 503 

treatment  of 504 

Accoucheur,  conduct  of,  during  the 

first  stage  of  labor 286 

conduct  of,  during  the  second 

stage  of  labor 297 

conduct   of,    during    the    third 

stage  of  labor 306 

Acute  tympanites 691 

Adherent  placenta 506,  524 

Adherent    placenta    in    hour-glass 

contraction 527 

Affections  of  the  bladder    during 

pregnancy 229 

After-pains 320 

After-treatment  of  hemorrhage 518 

Agglutination  of  the  os  uteri 384 

Albuminuria  during  pregnancy. . . .  225 

Alimentation  of  the  child 316 

artificial  316 

Allantois 120,  136 

Alvine  evacuations  of  the  child.  .316,  329 


PAGE 

Amnion 116 

Amniotic  fluid 117 

Amnii,  liquor  117 

excess  of 362 

Anorexia  during  pregnancy 217 

Anterior  commissure  of  the  vulva.     63 
Anterior  lip  of  os  uteri,  retention  of  374 

Anteversion  of  the  uterus  245 

Anus,  prolapsus  of 238 

Aorta,  compression  of,  by  Prof.  C.  D. 

Meigs 514 

Aphthae 72? 

symptoms  of , .  722 

treatment  of 723 

Apoplexy 553 

fi-tal 308 

Application  of  the  bandage 312 

blunt  hook , 585 

forceps  . . . , 602 

perforator 629 

Arch  of  pubes 22 

Areola,  in  pregnancy 196 

Arm,  presentation  of 337,  446 

Articulations  and  ligaments  of  pelvis    22 

Ascites  of  the  fetus 410 

Asphyxia,  fetal 307 

Attention  required  during  the  puer- 
peral state 318 

required  subsequent  to  labor. .  .'518 
Attentions  to  the  child. . .  .307,  314,  329 

Attitude  of  the  fetus 142 

Audible  signs  of  pregnancy 198 

Auscultation  in  pregnancy 198,  206 

Axis  of  the  inferior  strait 32 

of  the  pelvis 32 

Axis  of  the  superior  strait 30 

Bag  of  waters 280 

to  distinguish  from  fetal  scalp 

283,  293 
729 


730 


KING  S    ECLPXTTIC    OBSTETRICS. 


Ballottement 204 

Bandage,  application  of 312 

Baudelocque's  pelvimeter 47 

Beating  of  fetal  heart !!)'.» 

Bed,  putting  to 314 

Bladder,  affections  of 229 

calculus  in 248,  403 

descent  of 401 

rupture  of  549 

Blastoderuiic  vesicle 114 

Blunt  hook 585 

Body  of  the  uterus,  changes  iu,  dur- 
ing pregnancy 159 

Bones  of  the  fetal  head 54 

of  the  pelvis 16 

Breast?,  enlargement  of 195 

inflammation  of 700 

Breathing,   difficulty    during  preg- 
nancy    231 

Breech,  how  to  distinguish 432* 

Breech-labors,  management  of  diffi- 
cult  437,  442 

Breech-presentation 338,  431 

management  of 437 

positions  of 338,  433 

Brim  of  the  pelvis 20,  34 

Broad  ligaments 81 

Brow  presentation 411 

Bruit  de  souffle    198 

Caducous  membrane 109 

Calcaneo-iliac  positions 339 

Calculus  in  the  bladder  during  labor  403 

during  pregnancy 248 

Cancer  of  the  os  uteri 389 

Caput  succedaneum 283,  343,  349 

Cardialpria  during  pregnancy 219 

Caruncula?  myrtiformes 67 

Carus,  curve  of 32 

Cases  in  which  the  Cesarean  opera- 
tion may  be  performed ,  631 

Cases  for  turning 574,  576 

Cases  requiring  craniotomy 624 

Cases  requiring  forceps 595 

Catarrh,  nasal 726 

Catheterization 296,  402 

Cauliflower  tumor 386,  389 

Cause  of  labor 271 

Causes  of  abortion 250 

of  phlegmasia  dolens 680 


Causes  of  puerperal  fever 655 

of  puerperal  mania 692 

Causes  of  relaxation  and  separation 

of  the  symphysis 27 

Cautions  respecting  the  use  of  ergot  381 

Cavity  of  the  decidua 109 

Cavity  of  the  pelvis 16,  29,  32 

Cazeaux  on   diagnosis   of  placenta 

prsevia 490 

Cephallut'matoma 357 

Cephalalgia  during  pregnancy 222 

Cephalic  version 461,  575 

Professor  Wright's 461 

Cephalo-iliac  positions 447 

diagnosis  of 447 

Cervix  uteri 74 

changes  in  the 156 

fibrous  tumor  of  the 385 

Cesarean  operation t;:;i 

cases  in  which  it  may  be  used..  631 

dangers  of 631 

mode  of  performing 635 

when  to  be  perform*  d 635 

Cesarean  section 631 

Changes  in  the  body  of  the  uterus 

during  pregnancy 159 

Changes  in  the  cervix  uteri  during 

pregnancy 156 

Changes  in  the   properties  of  the 

uterus  during  pregnancy 166 

Changes  in  the  uterus  during  preg- 
nancy    156 

Character  of  labor,  determined ....  294 

Child,  apoplexy  of 308 

ascites  of 41  i) 

asphyxia  of 307 

attentions  to  the 307,  314 

delivery  of  the 283,  .304 

diseases  of  (see  Infai/i.«. 

food  for  the 316 

holding  the 309 

washing  the 314 

Child-bed  fever 654 

Children,  plurality  of 47"> 

still-born 307 

Child's  head,  delay  of,  in  the  pelvic 

cavity 389 

Chin  from  the  breast,  departure  of  411 

Chorion 115 

Cicatrix  in  the  vagina 387 


INDEX. 


731 


Circulation,  fetal 144 

Classification  of  labor 277 

Clitoris 64 

Coccyx 19 

Coccyx  in  difficult  labor 401 

Colic  of  infants 717 

Collection  of  feces  in  the  rectum .  .  .  403 

Colostrum 316 

Commissures  of  the  vulva 63 

Coin  plicated  labor 484 

Compound  pregnancy 475,  178 

presentations  ...    427 

Compression  of  the  aorta 514 

Concealed  hemorrhage 502 

diagnosis  of 503 

treatment  of 504 

Conception 100 

Condition  of  the  female  in  the  first 

stage  of  labor 

in  the  second  stage  of  labor. . . . 
Condition  of  the  uterus  in  the  first 

stage  of  labor 280, 

in  the  second  stage  of  labor. . . . 
Conduct  of  accoucheur  during  the 

first  stage  of  labor 286 

during  the  second  stage  of  labor  297 
during  the  third  stage  of  labor  306 

Constipation  during  pregnancy 220 

of  infants 717 

Contraction,  hour-glass 527 

irregular 360,  527,  534 

Contractions,  fibrillar 274 

painless  uterine 274 

uterine 271,  319 

Convulsions,  apoplectic 553 

during  pregnancy 223 

epileptic 554 

hysterical 224,  552 

Convulsions,  puerperal 552 

Cord,  around  the  neck 303 

cutting  umbilical 306 

hemorrhage  from 719 

umbilical 127 

umbilical  around  the  neck 303 

umbilical,  dressing  the 315 

prolapsus  of  the 469 

umbilical,  rupture  of  the 533 

umbilical,  shortness  of  the 407 

umbilical,  tying  of 306 

Corpus  Luteum 88 


Corpus    Luteum,    by    Prof.    C.    D. 

Meigs 

Coryza 

Cough  during  pregnancy 

Coutouly's  pelvimetcr 

Cramp  of  the  stomach  during  preg- 
nancy  

Cramps  during  pregnancy 

Cramps  during  labor,  treatment  of. 
Craniotomv.. 


cases  requiring 

dangers  of 

mode  of  operating 

Crede's  operation 

Cross-birth 

Crotchet 

Crural  phlebitis 

Crusta  lactea 

Curve  of  Carus 

Cutting  the  umbilical  cord. 
Cyanosis 

symptoms  of 

treatment  of 

Cystocele,  vaginal 


1)1 
726 
231 

49 

220 

2:',9 

300 
622 
624 
626 
627 
383 
44(5 
625 
681 
725 
32 
306 
713 
714 
714 
402 


Dangers  of  Cesarean  operation 631 

of  turning .576,  580- 

Davies'  forceps 587 

Death  of  the  fetus 153 

Decapitation 254 

Decidua,  cavity  of  the 109 

vera 110 

reflex 110 

serotina 110,  116,  124 

Deciduous  membrane 109 

Deficient  contractions 360,  378,  506 

lochial  discharge 325 

Deformities  of  the  pelvis 35,  393 

management  of,  in  labor. .  .394,  403 
Delay  of  child's  head  in  pelvic  cav- 
ity     389 

Delivery  in  natural  labor,  position 

for 289,  300 

Delivery  of  the  child 283,  304 

of  the  placenta 284,  310 

Departure  of  the  chin  from  the  breast  411 

Descent  of  the  head 343 

of  the  os  uteri 374 

Despondency  during  pregnancy. . . .  233 
Detachment  of  placenta 495,  507 


732 


KINGS    KCLECTIC    OBSTETRICS. 


Determination  of  the  scalp  from  the 

membranes 283,  293 

I  letermining  the  character  of  labor  294 

Development  of  the  fetus 128 

of  the  human  ovtim 109 

I  >ia.Lrnosis  of  abortion 250 

of  accidental  hemorrhage 503 

of  breech  presentation 432 

of  concealed  hemorrhage 503 

of  ear  presentation 424,  426 

of  face  presentation 414 

of  feet  presentation 445 

of  hour-glass  contraction 528 

of  inflammation  of  the  uterine 

appendages 662 

of  intestinal  irritation 698 

of  inverted  uterus 539 

of  knee  presentation 444 

of  left  occipito-anterior  position  342 
of  left  occipito-posterior  position  394 

of  occipito-pubal  position 348 

of  occipito-sacral  position 354 

of  pelvic  presentations 432 

of  phlegmasia  dolens 685 

of  placenta  prsevia 488 

of  prolapse  of  the  cord 470 

of  puerperal  mania 693 

of  puerperal  peritonitis 662 

of  right  occipito-anterior  position  347 
of  right  occipito-posterior  posi- 
tion    353 

of  rupture  of  the  uterus 545 

of  sex  of  fetus  in  utero 206 

of  shoulder  presentations 447 

of  transverse  presentations 469 

of  twins 180,  200 

of  uterine  phlebitis 666 

of  vertex  presentations 340 

Diameters  of  the  fetal  head 56 

of  the  inferior  strait *  . .     30 

of  the  pelvic  cavity 32 

of  the  superior  strait 29 

Diarrhea  during  pregnancy 218 

Diet  after  labor 317 

Differences  of  male  and  female  pelvis    33 
Difficult  brea'thingduringpregnancy  231 

Difficult  labor 278,  358,  377 

ergot  in 363,  380 

from  agglutination  of  os  uteri . .  384 
from  ascites  of  fetus. .  .  410 


Difficult  labor  from  calculus  in 

the  bladder 403 

from  cancer  of  the  os  uteri 389 

from  cauliflower  tumor ::sr. 

from  cicatrix  in  vagina 388 

from  condition  of  coccyx 401 

from  delay  of  the  child's  head..  389 

from  distension  by  twins Dill 

from  early  departure  of  the  chin  410 

from  encysted  tumors '.'>'.  1 1 

from  excess  of  liquor  amnii. . . .  361 

from  excrescences 3'.i2 

from  exostosis 390 

from  feces  in  the  rectum 403 

from  fibrous  tumors  of  the  cervix  :  >X5 

from  fungous  tumor 3X6 

from  hydrocephalus 409 

from  imperforate  hymen 389 

from  imperforate  os  uteri 384 

from  inefficient  uterine  contrac- 
tions..-.  36o.  37s 

from  mal-positions  of  the  head 

411.  41 :5,  424 

from  obliquity  of  os  uteri 1174 

from  obliquity  of  uterus '•'>!'- 

from  osdema  of  labia  inajora.  .  .  390 

from  ovarian  tumor 405 

from  pelvic  deformity 393 

from  pelvic  osteo-sarcoma 391 

from  pelvic  tumors 390 

from  phlegmonous  tumors 392 

from  polypus 3x5.  :  ;<  IL> 

from  premature  rupture  of  the 

membranes 375 

from  relaxed  abdominal  muscles  404 
from  rheumatism  of  the  uterus  362 
from  rigidity  of  membranes. . . .  375 

from  rigidity  of  os  uteri 365 

from  rigidity  of  soft  parts.  .374,  386 

from  scirrhous  tumors 31(2 

from  shortness  of  the  cord 407 

from  syphilitic  vegetations 3!  (2 

from  toughness  of  membranes .  375 

from  tumors 385,  3S6,\390 

from  tympanites  of  the  fetus.  ..411 

from  vaginal  cystocele 4(12 

from  vaginal  hernia 404 

from  vaginal  vesicocele 402 

in  first  stage 358 

in  second  stage 377 


733 


Difficult  labor,  breech,  management 

of 437,442 

Dilatation  of  the  os  uteri.  275, 278, 299,  387 

of  os  uteri  by  dry  cupping 387 

of  perineum 283 

Dimensions  of  the  fetus 54,  147 

Dimness  of  vision  during  pregnancy  230 
Discrimination  of  scalp  from  bag  of 

waters 283,  293 

Diseases  of  the  fetus 152 

of  the  pregnant  female 209 

Distension  from  twins 362 

Divisions  of  labor 277 

of  the  fetus 54 

Dr.  Washington  on  dry-cupping. . .  387 

Dressing  the  cord 315 

Dropsy  of  ovum 24S 

Dry-cupping  to  cause  dilatation  of 

os  uteri 387 

to  cause  uterine  contraction  . . .  387 
Duration  of  first  stage  of  labor  ....  281 

of  labor 271 

of  pregnancy 171 

of  second  stage  of  labor  . .  .283,  294 

of  third  stage  of  labor 284 

Duties  of  accoucheur,  after  delivery  312 
of  accoucheur  in  the  first  stage 

of  labor 286 

of  accoucheur  in  the  second  stage 

of  labor 297 

of  accoucheur  in  the  third  stage 

of  labor 306 

Dwarfish  pelvis 3D,  393 

Dyspnoea  during  pregnancy 231 

Ear  presentations 424 

diagnosis  of 425 

management  of 425,  427 

positions  of 424 

Early  departure   of  the  chin  from 

the  breast 410 

Eclampsia 552 

Embryonic  spot 87,  115 

Embryotorny 6.2 

Einbryotomy  forceps,  Meig's 629 

Encysted  tumors 391 

Enlargement  of  the  abdomen 19ii 

of  the  breasts 19". 

Ephelis . ...    194 

Ephemeral  fever 706 


Ephemeral  fever,  symptoms  of 706 

treatment  of 707 

Epigenesis,  theory  of 97 

Epilepsy 554 

Ergot,  cautions  respecting  the  use  of  381 

in  difficult  labors. . . '. 363,  3S1 

Ergot,  in  natural  labors 3D5 

Evolution,  spontaneous 459 

theory  of !  is 

Examination,  vaginal 288 

Excavation,  pelvic 32 

Excess  of  liquor  amnii 362 

Excessive  lochial  discharge 324 

Excoriated  nipples 327 

Excoriation  of  the  navel 719 

Excrescences 392 

Exhaustion,  symptoms  of 377,  599 

Exostosis 390 

Expulsion  of  the  head 283,  301 

of  the  placenta 284,  310 

Extension (JO 

External  organs (>1 

Extra-uterine  pregnancy ls:> 

Exvisceration 461 

Face  presentation 336,  414 

diagnosis  of 416 

mechanism  of 418,  420 

positions  of '......  .337,  418 

treatment  of 421 

Facial  nueralgia  during  pregnancy.  227 

Fainting 229 

Falling  of  the  womb 241,  331 

Fallopian  tubes 82 

False  pains 276 

treatment  of 277 

False  pregnancy 181,  187 

False  waters 1 16,  246 

Fecal  accumulation 403 

Fecundation 94 

Feet,  flow  to  distinguish   445 

Feet  presentation 339,  445 

diagnosis  of 445 

treatment  of 445 

Female  in  natural  labor 267,  279,  282 

organs  of  generation 61 

Fetal  apoplexy 308 

asphyxia 307 

circulation 1 44 

dimensions  and  weight 147 


7:J4 


KING'S  ECLECTIC  OBSTETRICS. 


I-Vtal  head,  diameters  of 56 

head,  expulsion  of 283,  301 

IK -art,  beating  of 199 

respiration 143 

iralp,  to  discriminate  from  bag 

of  waters 283,  293 

Fetus  and  its  development 1 28 

ascites  of 410 

attitude  of 142 

death  of 153,  254 

diseases  of 152 

full  developed 152 

its  divisions  and  dimensions. . .     54 

position  of 142 

signs  of  death  of 153.  254 

tympanites  of 411 

viability  of 176 

violent  movements  of 247 

Fever,  ephemeral 656 

irritative 534 

miliary 707 

milk 326 

puerperal  . .    654 

Fibrillar  contractions 274 

Fibrous  tumors  of  the  cervix 385 

Fifth  position  of  vertex 335,  353 

Fillet 581 

First  left  cephalo-iliac  position. 338,  446 

diagnosis  of 446 

First  position  of  vertex 334,  342 

First  right  cephalo-iliac  position. 338,  446 

diagnosis  of 446 

First  sacro-iliac  positions 433,  436 

First  stage  of  labor. 278,  286,  358 

condition  of  female  in 279 

condition  of  the  os  uteri  in.. 280,  281 

condition  of  uterus  in 280 

conduct  of  accoucheur  in 286 

duration  of 281 

inefficient  contractions  in 359 

management  of *  2S6 

mode  of  examination  in 288 

rheumatism  of  uterus  in 363 

rigidity  in 366 

Flatulent  colic  of  infants 717 

Fleshy  moles 256 

Flexion 59,  343 

Flooding  (see  Hemorrhage). 

Fluid,  amniotic    117 

Fontanelles,  and  sutures 54 


Food  tor  the  child :;io 

Forceps .  >s  > 

at  the  superior  strait 597,  615 

cases  requiring .'....  597 

1 'avis' :>,S7 

Hodges' :,ss 

in  breech  labors     620 

Forceps  in  face  presentations 61 7 

in  left  mento-iliac  positions. ...  617 
in  left  occipito-anterior  positions  ( ii  i7 
in   left  occipito-posterior    posi- 
tions      610 

in  left  occipito-transverse  posi- 
tions    G13 

in  mento-pubic  positions  (note).  618 
in  mento-saeral  positions  (note)  618 
in  occipito-posterior  positions 

(breech  labors) 621 

in     occipito-pubic    positions 

(breech  labors) 620 

in  occipito-pubic  positions 609 

in  occipito-sacral  positions  ....  'ill 

in  pelvic  presentations 620 

in  right  mento-iliac  positions  . .  618 
in  right  occipito-anterior  posi- 
tions    608 

in  right  occipito-posterior  posi- 
tions    Oil 

in  right  occipito-transverse  posi- 
tions  iil4 

in  vertex  presentation 6  )3 

mode  of  applying 603 

period  for  applying 599 

rules  for  applying (502 

use  of  the 595 

when  not  to  be  used 596 

when  the  face  is  at  the  superior 

strait 619 

when  the  head  is  at  the  superior 

strait 615 

Forehead  toward  the  pubic  arch.  .355,  4 1 2 

Fossa  navicularis 67 

Fourchette ( >3 

Fourth  position  of  vertex 335,  349 

Freenum 63 

Full  developed  fetus 1 58 

Fungous  tumor 386 

Funis,  ligature  of 306 

prolapsus  of 469 

short  . .  .407 


INDEX. 


735 


Funis  umbilicalis 127 

Galvanic  heat  in  inverted  uterus. . .   "45 

Galvanism,  in  premature  labor 051 

Gastrodynia,  dimng  pregnancy....   220 
Gastrotomy  (see  Cesarcan  operation)  . 

General  signs  of  pregnancy 192 

Generation 94 

Genitals,  itching  of 229,  233 

pustules  of 241 

Germinal  membrane 86,  114 

spot 87 

vesicle 80 

Gestation,  duration  of 171 

Graafian  vesicles So 

Great  sacro-sciatic  ligament 24 


Habit  of  aborting 2o5 

Hand-presentation 427 

Hand  and  foot  presentation 428 

Hare-lip 721 

Head  and  an  extremity  presenting. .  427 

delay  of,  in  pelvic  cavity 389 

descent  of 343 

extension  of 60,  345 

flexion  of 59,  343 

Dial-positions  of - 408 

of  child,  diameters  of 50 

positions  of  (see  Vertex). 
presentations  of  (see  Verte.r). 

presentations  of  side  of 424 

restittition  of 303,  345 

rotation  of 60,  344 

Headache  during  pregnancy 222 

Heart,  beating  of  fetal 199 

palpitation  of 23  L 

Heat,  galvanic,  in  inverted  uterus .  .  545 

Hematemesis 241 

Hemoptysis 24  L 

Hemorrhage 484 

accidental 502 

accidental,  diagnosis  of 503 

accidental,  treatment  of 504 

after-effects  of 520 

after  placental  delivery 509 

after  placental  delivery,  symp- 
toms of 510 

after  placental  delivery,   treat- 
ment of 511 

.after  the  chilli's  delivery 506 


Hemorrhage,  after-treatment  of 518 

before  full  term 502 

concealed 502 

concealed,  diagnosis  of 503 

concealed,  treatment  of 504,  508 

following  abortion 256,  258,  232 

i'rom  the  cord 719 

Hemorrhage,  from  the  navel 719 

from     placenta    preevia,    tre.;.- 

ment  of 4i  '2 

in  retained  placenta 506 

in  retained  placenta,  treatment 

of 507 

prevention  of 520 

puerperal 485 

reaction  of 520 

syncope  from 500,  518 

treatment  of  after-effects 521 

unavoidable 485 

uterine 484 

with  abortion 249,  258,  263 

with  adherent  placenta 506 

with  hour-glass  contraction ....  528 

with  inverted  uterus 542 

with  irregular  contraction 528 

with  placenta  prsevia 435 

Hemorrhoids 236 

Hernia 237 

umbilical 718 

vaginal 404 

Hodge's  forceps 589 

Holding  the  child 309 

Hollow  of  the  sacrum 17 

Hour-glass  contraction 5i'7 

Hydatids 181 

Hydrocele  of  infants 720 

Hydrocephalus 409 

Hydrorrhea 116,  238 

Hymen 66 

Hymen,  imperforate 66,  389 

Hysterical  convulsions 224,  552 

Hysteritis 664 

Ilio-pectineal  line 20 

Ilium 20 

Imperforate  hymen 389 

os  uteri 384 

Impregnation,  theories^  of 94 

Incontinence  of  urine 239 

Indications  of  mal-formed  pelvis. . .     47 


736 


KINGS    ECLECTIC   OBSTETRICS. 


Induction  of  premature  labor (140 

Inertia  of  the  uterus 524 

Ineliicient   action  of  the  uterus  in 

the  first  stage  of  labor 360 

in  the  second  stage  of  labor 378 

Infantile  uH'.-ctions 713 

Infants  (sec-  <  'hilil}. 

Infants,  colic  of 717 

constipation  of 717 

hydroeele  of 720 

jaundice  of 715 

ophthalmia  of 716 

retention  of  urine  in 715 

swelled  breasts  of 720 

Inferior  strait 16,  31 

axis  of 32 

diameters  of 31 

plane  of 32 

Inflammation  of  the  breasts 700 

symptoms  of 700 

treatment  of 702 

Inflammation  of  the  uterine  absorb- 
ents   667 

post-mortem  appearances  of...  667 

symptoms  of 667 

Inflammation  of  the  uterine  append- 
ages    66:-} 

diagnosis  of 664 

pi  ist-mortem  appearances  of. ...  664 

symptoms  of 664 

Inflammation  of  the  uterine  veins. .  (5(56 
post-mortem  appearances  of. . . .  666 

symptoms  of 000 

Inflammation  of  the  uterus 664 

Inflammatory  puerperal  fever,  treat- 
ment of 671 

Innominatum 20 

Innutrition 716 

Insanity  after  delivery (55)1 

during  pregnancy 232 

Interstitial  pregnancy 187 

Intestinal  irritation 697 

diagnosis  of (i'.ls 

prognosis  of 098 

symptoms  of 0!)8 

treatment  of 69S 

Inversion  of  the  uterus 5:',7 

diagnosis  of .  .»•* 538 

galvanic  heat  in 545 

prognosis  of 538 


Inversion  of  the  uterus,  symptoms 

of ". 5;;: 

treatment   of 540 

Irregular  contractions. 527,  534 

Irritability,    nervous,   during   preg- 
nancy     5:!4 

Irritative  fever  from  putrid  absorp- 
tion  265,  .">:;:> 

Ischia,  plane's  of 21 

Ischium 21 

Itching  of  the  genitals 229,  233 

Jaundice,  during  pregnancy 240 

of  infants 715 

Kiesteine 198 

Knee  presentation :;:',!) 

diagnosis  of 444 

treatment  of 445 

Labia  majora (>2 

oedema  of 3!)f» 

Labia  minora 63 

Labia  pudendi 62 

Labor 271 

attentions  required  after 318 

cause  of 271 

classification  of 277 

complicated 484 

condition  of  female  in  first 

stage  of 27!! 

condition  of  female  in  second  do.  282 
condition  of  os  uteri  in  first 

stage  of ' .280,  281 

condition  of  os  uteri  in  second 

stage  of 282 

condition  of  uterus  in  first 

stage  of 280 

conduct  of  accoucheur  in  first 

stage  of 286 

conduct  of  accoucheur  in  second 

stage  of ' 297 

conduct  of  accoucher  in  third 

stage  of 306 

difficult 27S,  35,s,  :;77 

difficult,  ergot  in 362.  380 

difficult,  from  mal-positions  of 

the  head 411,  413,  424 

difficult,  in  first-stage .'558 

difficult,  in  second  stage 377 


INDEX. 


737 


Labor,  divisions  of 277 

duration  of 271 

duration  of  first  stage  of 281 

duration  of  second  stage  of. 283,  304 

ergot  in  difficult 363,  380 

ergot  in  natural 305 

first  stage  of 278,  288 

induction  of  premature 640 

lingering  (see  Difficult  Labor). 

management  of  natural 285 

mechanism  of 340 

methods  of  inducing  premature  652 

Labor,  mode  of  examination  in  first 

stage  of 288 

position    for    delivery    in    na- 

ural 289,  300 

precipitate 383 

premature 270,  640 

premature,  induction  of 640 

premonitory  signs  of 273 

preternatural 429 

protracted  (see  Difficult  Labor). 

rigors  during 275 

rules  to  determine  the  character 

of : . . . .  294 

second  stage  of 282,  299 

tedious 278,  358 

third  stage  of 284,  306 

treatment  of  cramps  during  . . .  300 
treatment  of  difficult  breech  .437,  442 

treatment  of  twin 476 

twin 475 

Labor  pains 271,  276,  282 

false  276 

true 276 

with    pelvic    deformity,    treat- 
ment of  (note) 390 

Laceration  of  perineum 284 

of  vagina 549 

Laparo-elytrotomy 639 

Laxity  of    abdomen    during  preg- 
nancy   240 

Left  calcaneo-iliac  position 339 

Left  cephalo-iliac  positions 338 

diagnosis  of 447 

Left  lobulo-iliac  positions    424 

diagnosis  of 42(5 

Left  mento-iliac  position 337,  41.8 

diagnosis  of 418 

mechanism  of 419 

47 


Left  oecipito-anterior  position . .  334, 

diagnosis  of 

forceps  in 

mechanism  of 

Left  occipito-posterior  position.  .325, 

diagnosis  of 

mechanism  of 

Left  sacro-iliac  position 

diagnosis  of 

mechanism  of 

Lesser  sacro-sciatic  ligament 

Lever 

Ligament,  great  sacro-sciatic 

lesser  sacro-sciatic 

Ligament,  obturator 

Ligaments  and  articulations  of  pelvis 
Ligaments,  broad 

of  ovary 

of  uterus 

round    

sacro-sciatic 

Linea  ilio-pectinea 

Linear  albicantes 

Lingering  labor  (see  Difficult  Labor). 
Lip  of  os  uteri,  retention  of  anterior 
Liquor  amnii 

excess  of 

Lobulo-pubal  positions 425, 

Local  signs  of  pregnancy. . . , 

Lochia 284, 

deficient.. . 


excessive  .t 

Locked  head  (note) 

Longings  during  pregnancy 


342 

333 

607 

343 

610 

350 

351 

339 

432 

433 

25 

582 

25 

25 

25 

23 

81 

84 

81 

82 

25 

20 

319 

374 
117 
362 
426 
193 
323 
325 
324 
401 
217 


Making  the  bed 295 

Malacosteon    37 

Male  and  female  pelves 33 

Malformation  of  the  pelvis 34 

indications  of 47 

Malpositions  of  the  head 414 

Mammary  abscess 700 

Management  of  breech-presentation  437 
of  difficult  breech  labors. .  .437,  442 

ear  presentations 425,  427 

face  presentation 423 

feet  presentation 445 

knee  presentation 444 

labor  with  pelvic  deformity.  394,  403 
mento-iliac  positions 423 


738 


KING'S    ECLECTIC    OBSTETRICS. 


Management  of  monstrosities 483 

natural  labor 285 

shoulder  presentations 449 

twin  labor 477 

Mania  during  pregnancy 232 

puerperal <>'.>! 

Masto  lynia. 231 

.Measurement  of  the  pelvis 48 

Meatus  urinarius 65 

Mechanical  vomiting  in  pregnancy.  214 

Mechanism  of  labor 340 

left  mento-iliac  position 418 

left  occipito-anterior  position  . .  343 
left  occipito-posterior  position  .  350 
left  sacro-iliac  positions  ....  433,  436 

occipito-pubal  position 349 

occipito-sacral  position 344 

Mechanism  of  right  mento-iliac  posi- 
tion    421 

right  occipito-anterior  position .  348 
right  occipito-posterior  position.  354 
right  sacro-iliac  positions. .  .436,  437 

Meconium 152,  316 

Meconium,  purging  the 316 

Meig's  etnbryotomy  forceps 625 

Membrana  caduca 109 

decidua 109 

Membrane,  caducous 109 

deciduous 109 

germinal 86,  114 

vitelline 86 

Membranes,  premature  rupture  of. .  375 

rigidity  of ! 375 

rupture  of 280,  375 

toughness  of 375 

Menstruation 100 

suppressed,  a  sign  of  pregnancy  193 
Methods  of  inducing  prema'ture 

labor 646 

Metritis 664 

post-mortem  appearances  of. ...  665 

symptoms  of 665 

Miliary  fever. / 707 

symptoms  of 707 

treatment  of 708 

Milk  fever 326 

Milk-leg 680 

Miik,  socretion  of,  in  pregnancy.  .  .  .    196 

M  iscarriage 249 

Mixed  pregnancy 178 


Mobility  of  the  pelvic  articulations.     26 

Mode  of  applying  the  forceps 602 

Mode  of  examination  in  first  stage 

of  labor 288 

.Mode  of  performing craniotomy.  . . .   627 
Moles 181 

fleshy :_>:>;; 

Molesworth's  climax  dilator 6  ~>3 

Mollifies  ossium 37 

Mons  veneris 61 

Monsters 1 H),  482 

Monstrosities,  management  of 483 

Morbid  adhesion  of  placenta -    531 

treatment  of 533 

Morph 193 

Mother's  marks 719 

Mueo-serolent  discharge 274 

Mucous  discharges  from  vagina ....  241 

Multiple  pregnancy 17s.  475 

Muscular  pains  during  pregnancy. .   233 

Nsevus  materni 719 

Nasal  catarrh 728 

Natural  labor,  position  for  delivery 

28:  l,  300 

Nausea  during  pregnancy 194 

Navel,  excoriation  of 719 

hemorrhage  from 719 

Navel  string 127 

Nervous    irritability    during    preg- 
nancy     234 

Nervous  shock 318 

Nidation 1 07 

Nipple,  excoriated 327 

sore 327 

sore,  treatment  of 328 

Nursing  sore  mouth 709 

Nyniphse S3 

Obliquely  distorted  pelvis 42.  393 

Obliquity  of  os  uteri 373 

of  uterus 372 

Obstetrical  instruments 5S6 

Obstetrical  operations 586 

Obturator  foramen 22 

ligament 25 

Occipital  positions 334,  342 

Occipito-pubal  position 334,  348,  620 

diagnosis  of 348 

mechanism  of ..  .   349 


INDEX. 


739 


Occipitb-sacral  position 336,  354,  (521 

diagnosis  of 354 

mechanism  of 354 

•Odontalgia  during  pregnancy -'11 

(Edema  during  pregnancy 234 

(Edema  of  'labia  majora 390 

Omphalo-mesenteric  vessels 11!) 

Operation,  Cesarean 631 

Operation  of  craniotomy 622 

Operative  midwifery    573 

Operation,  Sanger-Cesarean 034 

Ophthalmia  of  infants 716 

Organs  of  generation 61,  68 

Orifice  of  the  urethra 65 

Os  basilare 17 

Os  coccyx 19 

Os  ilium 20 

Os  ischium 21 

Os  pubis 22 

Os  uteri 74 

( )s  uteri,  agglutination  of 384 

cancer  of 389 

descent  of 374 

dilated  by  dry-cupping 387 

dilatation  of 275,  27<S,  :5S7 

imperforate   384 

obliquity  of - 373 

obliteration  of 384 

retention  of  anterior  lip 374 

rigidity    of,    in    first    stage    of 

labor 281,  366 

rigidity  of,   in  second  stage  of 

labor 387 

Ossa  innominata 20 

Osteo-sarcoma  of  pelvis 391 

Ovaries 83 

Ovarian  pregnancy 185 

Ovarian  tumor 405 

Ovular  theory 99 

Ovule,  or  human  egg 85,  128 

Ovum,  development  of 109 

dropsy  of 248 

Pain  in  the  right  side  during  preg- 
nancy    239 

Pain,  muscular,  during  pregnancy..  232 

Painless  uterine  contractions 274 

Pains,  after 320 

false 276 

irregular 527 


Pains  of  labor 271,  276,  282 

preparatory 271.  27<i,  2S2 

treatment  of  false 277 

Palpation,  abdominal 203 

Palpitation  of  the  heart 230 

Parietal  pregnancy 187 

Parturition 271 

Pathology  of  puerperal  convulsions  5<>3 
Pelvic  articulations,  mobility  of. ...     26 

Pelvic  cavity,  diameters  of 33 

planes  of. ; 32 

tumors  in 390 

Pelvic    deformities,    difficult    labor 

from 390 

management  of  labor  with  (note) 

391,  392 

Pelvic  presentations 338,  437,  439 

diagnosis  of 440 

management  of 437,  445 

mechanism  of 433,  437 

Pelvic  symphyses 23 

Pelvimeter,  Baudelocque's 48 

Coutoully's 49 

Pelvimetry 48 

Pelvis,. 16 

abnormally  large 39,  .",93 

articulations  of 23 

axis  of 28 

bones  of 15 

brim  of ,.20,  34 

cavity  of 16,  29 

deformities  of 35 

diameters  of 29 

dwarfish 39,  393 

Pelvis,     indications    of    malforma- 
tion of 47 

obliquely  distorted 42,  393 

osteo-sarcoma  of 391 

straits  of 29 

unequally  contracted 40,  393 

Pendulous  belly.. 312 

Perforator (530 

Perineum 67 

dilatation  of 283 

rigidity  of 68,  3S6 

support  to  the 67,  301,  606 

Period  for  applying  forceps 599 

for  turning 576 

Peritonitis 654,  660 

Phlebitis,  crural 680 


740 


KINGS    ECLECTIC    OBSTETRICS. 


Phlebitis,  uterine 654 

Phlegmasia  dolens 680 

causes  of 080 

diagnosis  of 685 

post-mortem  appearances  of ...  (586 

prognosis  of 685 

symptoms  of 684 

treatment  of 686 

Phlegmonous  tumors 392 

Piles  during  pregnancy 236 

Placenta 123 

adherent 506,  524 

delivery  of 284,  310 

detachment  of 494,  507 

expulsion  of 284,  310 

hemorrhage  after  delivery  of. . .  509 

morbid  adhesion  of 531 

putrescence  of 256,  534 

retained 506,  523 

retained,  treatment  of 507,  524 

retention  of 506,  524 

Placenta,  retention  of,  from,  irreg- 
ular contraction - ....  527 

retention  of,  from  morbid  adhe- 
sion    531 

retention  of,   from   uterine   in- 
ertia    523 

symptoms  of  hemorrhage  after 

delivery  of 510 

treatment  of  hemorrhage   after 

delivery  of >...  511 

Placenta  pnevia 485 

diagnosis  of 488 

hemorrhage  from 485 

treatment  of 491 

Placental  presentation 485 

sound 198 

Plane  of  inferior  strait 32 

of  the  superior  strait 30 

Planes  of  the  ischia 21 

of  the  pelvic  cavity 32 

Plethora  during  pregnancy 226 

Plurality  of  children 475 

Podalic  version 400,  575 

Polypus 385 

Porrigo  larvalis 717 

Porro-Cesarean  operation 633,  639 

treatment  of 717 

Position,  first  left  cephalo-iliac .  .338,  447 
first  right  cephalo-iliac 338,  447 


Position,  first  vertex 334,  342: 

fifth  vertex 335,  353 

for  delivery  in  natural  labor.  289,  300 

fourth  vertex 335,  34!) 

left  calcaneo-iliac 339 

left  mento-iliac .337,  419 

left  mento-iliac,  diagnosis  of . . .  416 

left  mento-iliac,  mechanism 418 

left  occipito-anterior 334,  342 

left  occipito-anterior,  diagnosis 

of 342 

left  occipito-anterior,  mechan- 
ism of 343 

left  occipito-posterior 335,  34!) 

left  occipito-posterior,  diagnosis 

of 349 

left  occipito-posterior,  mechan- 
ism of 350 

left  sacro-iliac 339,  433,  436 

left  sacro-iliac,  diagnosis  of  .4.'!:!,  4:!(i 
left  sacro-iliac,    mechanism    of 

of 433,436 

occipito-pubal 334,  348 

occipito-pubal,  diagnosis  of 349 

occipito-pubal,  mechanism  of..  349 

occipito-sacral 335,  355 

occipito-sacral,  diagnosis  of ....  355. 
occipito-sacral,  mechanism  of ..  355 

of  the  fetus 142 

right  calcaneo-iliac ...  339 

right  mento-iliac 337,  421 

right  mento-iliac,  diagnosis  of. .  421 
right  mento-iliac,  mechanism  of  421 

right  occipito-anterior 334,  347 

right  occipito-anterior,  diagnosis 

of 347 

right  occipito-anterior,  mechan- 
ism of 347 

right  occipito-posterior 335,  353 

right    occipito-posterior,     diag- 
nosis of 353 

right  occipito-posterior,   mech- 
anism of 354 

right  sacro-iliac 339,  436 

right  sacro-iliac,diagnosis  of  .436,  437 
right  sacro-iliac,  mechanism  of 

436,  437 

second  left  cephalo-iliac 338,  446 

second  right  cephalo-iliac..  .338,  446 
second  vertex 334,  347 


INDEX. 


741 


'Position,  sixth  vertex. . .  .• 335,  554 

third  vertex 3:54,  34S 

Positions  and  presentations 332 

left  lobulo-iliac 425 

left  lobulo-iliac,  diagnosis  of .  426,  427 

lobulo-pubal 424 

lobulo-pubal,  diagnosis  cf 425 

mento-iliac,  treatment  of 421 

of  breech  presentation 338,  433 

of  ear  presentation 424 

of  face  presentation 336,  418 

of  feet  presentation 339,  445 

of  shoulder  presentations  .  .337,  44(5 

of  vertex  presentation 334,  340 

right  lobulo-iliac 424 

right   lobulo-iliac,   diagnosis   of 

425,  42(5 

Post-mortem  appearance  of  inflam- 
mation of  uterine  appendages  (364 
appearances  of  inflammation  of 

uterine  veins  

appearances  of  metritis 

appearances  of  phlegmasia  do- 
lens  686 

Post-mortem   appearances  of  puer- 
peral peritonitis 663,  669 

Posterior  commissure  of  the  vulva.     63 

Precipitate  labor 383 

Pregnancy 171 

abdominal 186 

affections  of  the  bladder  during  229 

albuminuria  during 225 

anorexia  during 195,  217 

anteversio  uteri  during 245 

areola  in 196 

audible  signs  of 198 

calculus  during 248 

cardialgia  during 219 

cephalalgia  during 223 

changes  in  the  uterus  during. ..   156 

compound 178,  474 

constipation  during 220 

convulsions  during 224 

cough  during 231 

cramp  of  stomach  during 221 

cramps  during 239 

despondency  during ^  233 

diarrhea  during 218 

-difficult  breathing  during 231 

diseases  of 202 


Pregnancy,  dimness  of  vision  during  230 

dropsy  of  ovum  during 248 

duration  of 171 

dyspnea  during 231 

extra-uterine 183 

facial  neuralgia  during 228 

fainting  during 2.50 

falling  of  the  womb  during.  . . .  241 

false 181,  188 

fetal  movements  during 248 

gastrodynia  during 221 

general  signs  of 192 

headache  during 22:5 

heartburn  during 195,  220 

hematemesis  during 241 

hemoptysis  during 241 

hemorrhoids  during 2:57 

hernia  during 248 

hydrorrhea  during 24(5 

incontinence  of  urine  during  .  .   241 

insanity  during 233 

interstitial 187 

jaundice  during 240 

laxity  of  abdomen  during 240 

local  signs  of . .  .• 193 

longings  during 217 

mania  during 2:53 

rnastodyn  ia  during 232 

mechanical  vomiting  in 214 

mixed 1 78 

multiple 178,  475 

muscular  pain  during 232 

nausea  during 195,  213 

nervous  irritability  during 233 

odontalgia  during 228 

oedema  during 235 

ovarian 1 85 

pain  in  right  side  during 240 

palpitation  during 230 

parietal 187 

piles  during 237 

plethora  during 226 

prolapsus  ani  during 238 

prolapsus  uteri  during 241 

prurieo  during 233 

pruritus  of  vulva  during 233 

ptyalism  during 217 

pustules  of  genitals  during.  .234,  241 

rational  signs  of 192 

retroversion  of  uterus  during..  242 


742 


RINGS    KCLKCTIC    OBSTETIMo. 


Pregnancy,  rheumatism  of  the  uterus 

during -47 

rigi  iiiy  of  abdomen  during 240 

salivation  during 217 

secretion  of  milk  during 190 

sensible  signs  of 192,  1^5 

sLrns  of 190 

sound  of  fetal,  heart  during.  . .  .    199 

spasm  of  stomach  during 221 

spasm  of  ureters  during 229 

spasm  of  uterus  during 240 

sub-peritoneo-pelvic 186 

suppressed  menses  during 193 

^ymp.ithftic  s'gns  ci 195 

syncope  during 230 

synopsis  of  signs  of 2()ii 

syphilis  during 248 

table  of  signs  of 208 

tangible  signs  of. 202 

toothache  during 197,  22X 

treatment  of  extra-uterine  ....  187 

tubal 186 

tubo-abdoodna] 187 

tubo-ovarian 187 

tumors  during 243 

twins 180,  200 

utero-tubal ]  87 

utero-tubo-abdominal 187 

vaginal  discharges  during 241 

varicose  veins  during 23(5 

ventral 18(5 

vertigo  during 230 

visible  signs  of 195 

vomiting  during 192,  21 3 

with  pelvic  deformity 248,  .",9:5 

Pregnant  female,  diseases  of 2i;9 

Premature  labor 249,  640 

modes  of  inducing 646 

Premature    rupture    of    the    mem- 
branes   375 

Premonitory  signs  of  labor 273 

Preparatory  pains 278 

Presentations  and  positions 332 

compound 427 

diagnosis  of  breech 432 

diagnosis  of  ear 425,  427 

diagnosis  of  face 416 

diagnosis  of  foot 445 

diagnosis  of  knee 444 

diagnosis  of  pelvic 432 


Presentations,  Diagnosis  of  plaeental  488 

diagnosis  of  shoulder 447 

diagnosis  of  transverse 469 

diagnosis  of  v  -rtex :i4() 

management  of  breech 4:',7 

management  of  ear 42 •>.  427 

management  of  f.ice 421 

management  of  feet 445 

management  of  knee 445 

management  of  plaeental 402 

management  of  shoulder 449 

management  of  transverse 46S 

management  of  vcrt.-x l".M 

of  an  extremity  with  the  head..   427 

of  the  breech 33S,  4:',1 

of  the  face 336,  414 

of  the  feet 339,  445 

of  the  knees 339.  444 

of  the  pelvic  extrrfinitie8..338,429,43] 

of  the  shoulder 337,  446 

of  the  side  of  the  he>.i: 424 

plaeental 485 

transverse 409,  (113,  614 

turning  in  shoulder 449 

vertex 334,  340 

Pressure  on  the  aorta 514 

Preternatural  labor 429 

Prevention  of  hemorrlu.g  • 520 

Prognosis  of  abortion 254 

Prognosis  of  intestinal  irritui" 09X 

of  inverted  uterus 539 

of  phlegmasia  dol"iis 6S5 

of  puerperal  convulsions 561 

of  puerperal  fever 670 

of  puerperal  mania 694 

•of  ruptured  uterus 547 

Prolapsus  ani,  during  pregnancy.  .  .   23S 

of  the  cord '.  .  .  .   469 

of  the  cord,  diagnosis  of 470 

of  the  cord,  treatment  of 471 

uteri,  during  pregnancy 241 

Promontory  of  the  sacrum 19 

Protracted  labor  (see  Difficult  Labor  . 

Prurigo  during  pregnancy 233 

Pruritus  of  the  vulva  during  preg- 
nancy    233 

Ptyalism  during  pregnancy 217 

Pubic  arch 23 

Pubic  symphysis 22,  24 

Pubis,  os 22 


INDKX. 


743 


Puerperal  convulsions 

causes  of 

pathology  of 

prognosis  of 

symptoms  of 

treatment  of 

Puerperal  fever 

causes  of 

prognosis  of 

treatment  of 

Puerperal  hemorrhage 486, 

Puerperal  mania 

causes  of 

diagnosis  of 

prognosis  of 

symptoms  of 

treatment  of 

Puerperal  peritonitis 654, 

diagnosis  of 

post-mortem  appearances  of. 663, 

symptoms  of (5(50, 

Puerperal  phrenitis 

Puerperal  septicemia 

diagnosis  of 

post-mortem  appearances  of. .  .  . 

prognosis  of 

symptoms  of ..-..' 

Pulse,  vaginal 

Pulsation  of  the  fetal  heart 

Purging  the  meconium 

Pustules  of  genital  organs,  during 

pregnancy 

Putrefactive  absorption. . .  .256,  265, 
Putrescence  of  placenta. . .  .256,  265, 

Putting  to  bed 

Pyemia,  puerperal 


233 
534 
534 
314 
667 


Quickening 1 97 

Rational  signs  of  pregnancy 192 

Reaction  of  hemorrhage 520 

Red  gum 715 

Relaxation  of  abdominal  muscles.. .  405 

Relaxation  of  the  symphyses 26 

Respiration,  fetal 142,  143 

Restitution  of  the  head 303,  346 

Retention  of  the  anterior  lip  of  os 

uteri 374 

Retention  of  the  placenta 524 

from  irregular  contractions.  .527,  534 


Retention  of  the  placenta  from  mor- 
bid adhesion 531 

from  uterine  inertia 524 

treatment  of 507,  524,  5:>.:'>,  535 

with  hemorrhage 506 

Retention  of  urine 22!),  322,  35!) 

of  urine  in  infants 715 

Retroversioii  of  the  uterus 292 

Rheumatism  of  the  uterus 246,  363 

Rickets 36 

treatment  of 36 

Right  ealcaneo-iliac  position 3:;',) 

cephalo-iliac  positions 33S,  447 

diagnosis  of 447 

Right  lobulo-iliac  positions 425 

diagnosis  of 425,  426 

Right  meuto-iliac  position 337,  419 

diagnosis  of 421 

mechanism  of 421 

Right  occipito-anterior  position. 334,  347 

diagnosis  of 347 

mechanism  of 347 

Right  occipito-posterior  position. 335,  3~i3 

diagnosis  of 353 

mechanism  of 354 

Right  sacro-iliac  positions 33!),  437 

diagnosis  of 437 

mechanism  of 437 

Rigid  abdomen  during  pregnancy. .  240 

Rigidity  of  the  m-embranc  s 375 

of  the  os  uteri 281,  365 

of  the  perineum 67,  374,  386 

Rigidity  of  the  soft  parts. . .  .67,  374,  386 

of  the  vagina 374,  386 

Rigors  during  labor 275 

Rotation  of  the  head 60,  344 

Round  ligaments : 82 

Rules  for  applying  the  forceps 602 

Rules  for  determining  the  charac- 
ter of  labor 294 

Rupture  of  the  bladder 549 

of  the  cord 533 

of  the  membranes 280,  375 

of  the  membranes,  premature..  375 

of  the  uterus  545 

of  the  uterus,  diagnosis  of 546 

of  the  uterus,  prognosis  of 547 

of  the  uterus,  symptoms  of 546 

of  the  uterus,  treatment  of 547 

of  the  vagina 549 


744 


KING'S    ECLECTIC    OI'.STKTKICS. 


Sacro-coccygeal   >yni|>hysis 25 

iliac  symphyses 24 

sciatic  ligaments 25 

Sacrum 17 

hollow  oi 17 

Sacrum,  promontory  of 19 

Salivation  during  pregnancy 210 

Sanger-Cesarean  operation 034 

Scirrhous  tumors 392 

Second  position  of  vertex 334,  347 

Second  stage  of  labor 2X2,  296 

condition  of  female  in 282 

condition  of  os  uteri  in 2S2 

conduct  of  accoucheur  in 297 

difficult 377 

duration  of 283,  304 

inefficient  contractions  in 378 

left  cephalo-iliac  position 338 

management  of 299 

right  cephalo-iliac  position 338 

rigidity  in 366 

Secretion  of  milk  during  pregnancy  196 

Section,  Cesarean 631 

Sensible  signs  of  pregnancy 192,  19.") 

Separation  of  the  symphyses 26 

treatment  of 28 

Septicemia ..256,264,  534,  667 

Shock  to  the  nervous  system 318 

Shortness  of  the  cord 407 

Shoulder  presentations 337,  44(> 

cephalic  version  in 460,  576 

diagnosis  of '. .  446 

management  of 449 

Shoulder    presentations,    positions 

of 337,  446 

turning  in 449 

Show ' 274 

Signs  of  labor,  premonitory 273 

Signs  of  pregnancy 190 

audible 198 

death  of  fetus 153,  254 

general 192 

local ». 193 

rational 192 

sensible 192,  193 

sympathetic 195 

synopsis  of 206 

table  of 206 

tangible 200 

visible  . .                                     .  195 


Sinking  of  the  xiterus 273 

Sixth  position  of  vertex 335,  :;55 

Snuffles 728 

Soft  parts,  rigidity  of 67,  :'>Sii 

Sore  mouth  of  nursing  women  ....   709 

Sore  nipples 327 

Sound  of  fetal  heart 199 

Sound,  placental 1 9S 

Spasm  of  stomach,  during  pregnancy  i'L'2 
of  ureters,  during  pregnancy. .  .  230 
of  uterus,  during  pregnancy.  .  .  247 

Spine  of  the  ischium 21 

Spontaneous  evolution 459 

Spot,  embryonic S7,   115 

spot,  germinal 87 

Stages  of  labor 278 

Still-born  children 31)7 

Strait,  inferior 31 

axis  of 32 

diameters  of 31 

plane  of 32 

Strait,  superior f 6,  29 

axis  of 30 

diameters  of 29 

plane  of 30 

Straits  of  the  pelvis 29 

Strophulus  intertinctus 715 

Sub-peritoneo-pelvic  pregnancy  ...    186 

Subsidence  of  the  abdomen 273 

of  the  uterus 27:! 

Superfetation  1 54 

Superior  strait 16,  29 

axis  of 30 

diameters  of  . . . . , 29 

Superior  strait,  plane  .of 30 

Support  to  the  perineum. . .  .07,  301,  607 
Suppressed  menses  in  pregnancy. .    19:; 

Sutures  and  fontanelles 54 

Swelled  breasts  of  infants 720 

Sympathetic  signs  of  pregnancy  ...    195 

Symphyseotomy 639 

Symphyses,  pelvic 23 

Symphysis,  sacro-coccygeal 25 

eacro-iliac 24 

pubis 24 

Symptoms    indicating  interference 

377,  599 

of  abortion 253 

of  aphtha1 722 

of  cyanosis 714 


INDEX. 


745 


Symptoms  of  death  of  fet-us. . .  .153,  255 

of  ephemeral  fever 70(5 

of  exhaustion 377,  599 

of  hemorrhage  after  delivery  . .  510 
of  inflammation  of  the  breasts.  700 
of  inflammation  of  the  uterine 

absorbents 667 

of  inflammation  of  the  uterine 

veins 663 

of  intestinal  irritation 698 

of  inverted  uterus 538 

of  metritis 664 

of  miliary  fever 709 

of  nursing  sore  mouth 711 

of  phlegmasia  dolens 0X4 

of  puerperal  convulsions 558 

of  puerperal  mania 692 

of  puerperal  fever 6(50,  1567 

of  puerperal  peritonitis. . .  .6(50,  667 

of  rupture  of  the  uterus 546 

of  uterine  phlebitis 665 

Syncope  during  labor , 549 

during  pregnancy 230 

from  hemorrhage 500,  518 

Synopsis  of  signs  of  pregnancy....  206 

Syphilis  as  a  cause  of  abortion  ....  250 
during  pregnancy 248 

Syphilitic  vegetations 392 

Table  for  determining  the  time  of 

labor 174 

Table  of  signs  of  pregnancy 206 

Tache  embryonnaire 115 

Tampon  259,  261,  497 

Tangible  signs  of  pregnancy 200 

Tedious  labor  (see  Difficult  Labor). 

Theories  of  impregnation 94 

Theory  of  epigenesis 97 

of  evolution 98 

ovular 99 

Third  position  of  vertex 334,  348 

Third  stage  of  labor 284,  306 

conduct  of  accoucheur  in 306 

Thrombus 550 

treatment  of 551 

Thrush 722 

Tongue-tied  infants 720 

Toothache  during  pregnancy 195,  229 

Toughness  of  the  membranes 375 

Tractor 582 

\ 


Transverse  presentations 

Treatment  of  abortion 

of  accidental  hemorrrhage 

of  after-effects  of  hemorrhage  .  . 

of  after-pains 

of  aphtha: 

of  breech  presentations 

of  concealed  hemorrhage. .  .504, 

lit"  convulsions 

of  coryza 

of  cramps  during  labor 

<  if  cyanosis 

of  difficult  breech  labors.. .  .437, 

of  ear  presentations 425, 

of  ephemeral  fever 

of  extra-uterine  pregnancy 

of  face  presentations 

of  false  pains •. 

of  foot  presentations 

of  habitual  abortion 

of  hemorrhage  after  delivery. . . 
of  hemorrhage  before  term.. 259, 
of  hemorrhage  from  placenta 

prsevia 

of    hemorrhage   with    retained 

placenta 

of  hour-glass  contraction 

of  inefficient  action  of  uterus..">60, 
of  inflammation  of  the  breasts. . 
of  inflammatory  puerperal  fever 

of  intestinal  irritation 

of  inverted  uterus 

of  knee  presentations 

of  labor  with  pelvic  deformity 

(note) 394, 

of  mcnto-iliac  positions 421, 

of  miliary  fever 

of  monstrosities 

of  natural  labor 

of  nursing  sore  mouth 

of  obliquity  of  uterus 

of  ovarian  tumor 

of  phlegmasia  dolens 

of  placenta  praevia 

of  porrigo  larvalis 

of  prolapsed  cord 

of  puerperal  convulsions 

of  puerperal  fever 

of  puerperal  hemorrhage491 , 507, 
of  puerperal  mania 


46s 
256 
504 
521 
321 
72:; 
437 
506 
554 
729 
300 
714 
442 
427 
70(5 
187 
421 
277 
445 
265 
511 
504 


507 
529 
378 
702 
671 
699 
540 
444 

403 
617 
708 
483 
285 
709 
373 
405 
686 
491 
727 
471 
565 
671 
511 
694 


74(i 


KINO'S    KCIJ-XTIC    OUSTKTIMo. 


Treatment  of  puerperal  peritonitis..   691 
of  reaction  after  lieinorrliage.  .  .   521 

of  relaxation  of  symphyses 28 

<  if  retained  placenta. .507,  524, 5:'>.">, .">:'>6 
of  rheumatism  of  t  lie  uterus. 246,  365 

of  rickets 36 

of  ri-ridity  of  os  uteri 2*1.  :;ii7 

of  rupture  of  tlie  uterus 547 

of  s  -pa ration  of  the  syniphyses.     28 

of  septieemia 264.  .").",."i 

of  shoulder  presentations 449 

( if  si  »re  nipples :'>27 

of  thrombus .V>1 

of  transverse  presentations. 469,  613 

of  trisnms  nascentium 726 

of  twin  labors 477 

of  typhoid  puerperal  fever 677 

of  unavoidable  hemorrhage. . . .  491 

Tremors  during  labor 275 

Trisnms  nascentium 725 

treatment  of 726 

True  labor-pains 276 

Tubal  pregnancy 187 

Tubes,  Fallopian 82 

Tubo-abdominal  pregnancy 187 

Tubo-ovarian  pregnancy 187 

Tumor,  cauliflower 386 

fibrous 385 

fungous 386 

ovarian 405 

phlegmonous 392 

scirrhous 392 

Tumors  during  pregnancy 248 

in  difficult  labor 390 

i)i  pelvic  cavity 390 

Turning 400,  449,  574 

cases  for 574,  57li 

dangers  of 576,  579 

Turning,  in  shoulder  presentations.  449 

period  for 567 

Twins 180,200,475 

diagnosis  of 180,  200,  476 

distension  from 362 

Tympanites,  acute 698 

Tympanites  of  the  fetus 411 

I'lcerated  nipples 327 

Umbilical  cord 127,  306,  533 

cutting  the 306 

prolapsus  of.. 469 


I'mbilical  cord,  shortness  of 407 

treatment  of  prolapsed 471 

I'mbilical  hernia 71s 

vesicle 1  IS 

Unavoidable  hemorrhage 4S4 

treatment  of 491 

Unequally  contracted  pelvis 40,  393 

Unruptured  hymen 389 

rraclms li'l 

Ureters,  spasm  of.  during  pregnancy  22S 

I'rethra.  orifice  of  the 65 

Urine,  incontinence  of 241 

retention  of,  in  infants 715 

Use  of  ergot,  cautions  respecting. .  .   3S1 

Use  of  the  forceps 595 

I  'terine  absorbents,  inflammation  of  667 
Uterine  appendages,  inflammation 

of 663 

Uterine  contractions 271,  320,  378 

by  dry-cupping :!S7 

painless 274 

Uterine  hemorrhage 4S4 

treatment  of 491,  504,  507,  51 1 

Uterine  inertia,  with  hemorrhage..   5<)6 

with  retained  placenta 524 

Uterine  phlebitis 666 

diagnosis  of 667 

post-mortem  appearances  of.. . .  667 

symptoms  of 666 

Uterine  prolapsus  during  pregnancy  24 1 

Uterine  veins,  inflammation  of 666 

Utero-tubal  pregnancy 187 

Utero-abdominal  pregnancy is? 

Uterus 71 

anteversion    of,    during    preg- 
nancy   ' 245 

broad  ligaments  of 81 

changes  in,  during  pregnancy.  .   156 
condition  in  first  stage  of  labor. .  2so 

diagnosis  of  inverted "•:'>'.' 

Uterus,  diagnosis  of  ruptured 546 

galvanic  heat  in  inverted 545 

hour-glass  contraction  of 5-J7 

inefficient  action  of 360.  :!7s 

inflammation  of 664 

inversion  of 5: ',7 

ligaments  of 81 

obliquity  of 373 

prognosis  of  inverted 5: $9 

prognosis  of  ruptured 547 


747 


Uterus,  rheumatism  of 246,  .'Hi:; 

retroversion   of,    during    preg-        . 

nancy 242 

round  ligaments  of 82 

rupture  of 545 

sinking  of 273 

spasm  of,  during  pregnancy.. . .  246 

subsidence  of 273 

symptoms  of  inverted 537 

symptoms  of  ruptured 546 

treat  Mi1  nt  of  inverted 540 

treatment  of  ruptured 547 

Vagina 6X 

cicutrix  in 3S7 

lacei'ation  of 54!) 

rigidity  of 374 

rupture  of 549 

Vagina!  cvstocele 402 

examination   in   first    stage    of 

labor 287 

hernia 406 

mucous  discharges 241 

pulse 169 

vesicocele 404 

Varicose  veins  during  pregnancy. . .  235 

Vectis 582 

Vegetations,  syphilitic 392 

Ventral  pregnancy 186 

Vernix  caseosa 141,  151,  314 

Version 400,  574 

cephalic 461,  574 

pndalic 400,  575 

Vertex  presentation '. . .  334 

diagnosis  of 340 

forceps  in 602 

mechanism  of 343 

positions  of 334,  340 


Vertigo  during  pregnancy 

Vesicle,  blastodermic 

germinal 86, 

umbilical 114, 

Vesicle,  Graafian 

Vesicula  umbilicalis 

Vessels,  omphalo-mesenteric 

Vestibulum 

Viability  of  fetus 

Violent  fetal  movements 

Visible  signs  of  pregnancy 

Vital   changes  in  the  uterine   tis- 
sues during  pregnancy 

Vitelline  membrane 

Vitellus,  or  yelk 

Vomiting  during  pregnancy  195,  211, 

Vomiting  in  labor 279, 

Vulva 

anterior  commissure  of 

posterior  commissure  of 

Vulva,  pruritus  of 

Washing  the  child 

Washington,  Dr.,  on  dry-cupping. . 
Waters,  bag  of 

bag  of,  to  distinguish  from  fetal 
scalp 283, 

false 116, 

Weed 

Weight  and  dimensions  of  the  fetus 

Woman 

Woman  in  labor 

Womb,  falling  of 

WTright,  Prof.  M.  B.,  on  cephalic 


230 

114 

114 

118 

85 

ll.s 

119 

64 

176 

247 


L62 

86 

86 

213 

282 

62 

63 

63 

233 


387 
2SO 

293 

246 
706 
147 
11 
278 
241 


Yelk,  or  vitellus 86 


THE  END. 


ECLECTIC  TEXT  BOOKS. 

IK  )\VK.   A.  JACKSON.  M.  I).     Professor  of  Surycry  in  tin-  Eclectic  Medical  I n-t it utc.  Cincinnati. 

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KIN<;,  JOHN,  M.  1).    Emeritus  Professor ot  Obstetric-sin  the  Eclectic  Medical  Institute.  Cincinnati. 

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LLOYD,  J.  I".     Professor  of  Chemistry  and  Pharmacy  in  the  Eclectic  Medical  Institute.  Cincinnati. 

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\VINTERMUTE,  ROBERT  C.,  M.  D.    Professor  of  Obstetrics  in  the  Eclectic  Medical  Institute. 

-King's  Eclectic  Obstetrics.— 


Ninth  Edition.    Thoroughly  revised  and  re-written.    Svo.  ,  750  pages  ;  Sheep:  Pric.     - 


Any  book  in  this  list  sent  fuxt-jmid,  on  receipt  of  jn-ir,-. 

THE  OHIO  VALLEY  CO,,  Publishers,  Cincinnati, 


Date  Due 


PR.NT.D  IN  u.*.*.  CAT.   NO.   24    161 


IHHH IIH  III"  ••'» ll111  •"• 

A  000511  620  7 


WQIOO 

K53k 
1892 

King,  John,  1813-1893. 

Kingfs  eclectic  obstetrics. 


WQIOO 
K53k 
1892 
King,  John,  1813-1893. 

King*s  eclectic  obstetrics. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


